Mom's Place 2

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at approximately 10:30 A.M. Upon arrival, the LPA knocked on the door; however, there was no response. The LPA also observed the facility was undergoing renovations and no individuals were present. The LPA contacted facility representative, Laila Kulungu, and explained purpose of the visit. Caregiver, Fidel Francisco, was subsequently sent to the facility to provide assistance and sign today’s report on their behalf. Entrance Interview. The LPA and the caregiver conducted a walk-through of the facility. The LPA confirmed all rooms were vacant, with no staff present and no care or supervision was provided at the time of the visit. The Licensee confirmed that all residents had been relocated, with responsible party approval, to a sister facility. The Licensee further stated the facility is not closing but will undergo renovations. Exit interview was conducted, and copy of the report was issued via email.the state’s words, verbatim · CDSS document, Apr 18, 2026

Type of visit: POC

At 10:56 A.M. LPA Conway conducted an unannounced Plan of Correction (POC) visit to follow up regarding the plan of corrections that were due for submission. The LPA was greeted by Nonso Enemchukwu. LPA informed the reason for the visit. Caregiver contacted the facility representative by phone, Laila Kulungu. At 11:56 A.M. facility representative arrived. At 11:57 A.M. Licensee, Joseph Jose, was contacted by phone and informed of LPA’s visit. Neither administrator nor Licensee were available during today's visit. due to distance, but authorized facility representative, to sign today's reports. Reason for the visit was stated. Entrance interview conducted. During required annual visit on 04/16/25, LPA cited CCR 87219(h)(1) with a due date of 04/30/2025 and CCR 87412(d) with a due date of 05/01/2025. As of today, these two (2) plans of corrections for deficiencies cited have not been cleared. On 04/24/25, LPA Conway, requested information from the Administrator Certification Bureau (ACB) Department regarding the status of the administrator on record. In response, the ACB indicated that administrator on record, Yusuf Ibironke, has administrator certificates for RCFE: 7033113740. Expiration date: 1/16/2025 and ARF: 7033113735. Expiration date: 4/5/2023. According to ACB records, no renewal applications have been received at this time. Continued on LIC 809-C Continued from LIC 809 In regard to the facility’s patio area, which was found to be inadequately furnished during the required annual visit, the LPA requested that the licensee provide proof of purchase and a photo of the installed patio furniture by 04/30/25. On 05/01/25, the LPA emailed facility representative to follow up, as the due date had passed without submission. On 05/02/25, the facility representative texted proof of purchase, indicating a scheduled delivery time of 11 A.M. on the same day. The LPA requested a photo of the installed patio furniture be submitted by the end of the day on 05/05/2025. During today’s visit LPA observed unopened boxes containing patio furniture on the facility premises. While conducting this visit facility staff assembled patio furniture. POC met. A civil penalty of $100 per 5 days was assess for not correcting deficiency under CCR 87412(d), and a civil penalty of $100 per 6 days was assess for not correcting deficiency under CCR 87219(h)(1) before the POC due date (Refer to LIC 809D from original annual visit on 4/16/2025). During today’s visit, at 12:00 P.M., LPA conducted a physical plant tour inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following deficiency was observed. The fire door was once again improperly held open using a doorstop. During the annual visit on 04/16/25, facility representative acknowledged that the door would remain closed at all times in compliance with fire safety requirements. An immediate civil penalty of $1,000 repeat violation is assessed today due to being cited for the same violation within 12 months. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC809-D). Exit interview conducted, deficiencies cited, civil penalties assessed, appeal rights discussed, and a copy of this report issued to the facility representative.the state’s words, verbatim · CDSS document, May 6, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: May 6, 2025

87202(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal... fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above by having the fire door improperly held open by an industrial doorstop which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Facility staff immediately closed the door during today's visit. Facility representative that the door would remain closed at all times in compliance with fire safety requirements.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:10 A.M. The LPA was greeted by Caregiver Kazim Albert. LPA informed the reason for the visit. Caregiver contacted the facility representative by phone, Laila Kulungu. At 10:35 A.M. facility representative arrived. At 10:37 A.M. Administrator, Yusuf Ibironke, was contacted by phone and informed of LPA’s visit. Administrator was unavailable during today's visit. Administrator stated that she not able come to the facility often due to distance, but authorized facility representative, to sign today's reports. Reason for the visit was stated. Entrance interview conducted. At 10:45 A.M. LPA conducted a physical plant tour inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Fire extinguisher was last serviced 11/16/2023. During today’s visit, staff bought two (2) new fire extinguishers. At 11:22 A.M. the smoke detectors and carbon monoxide detectors are combined units; they were tested and functioned properly. Per facility representative there is a fire door to enhance safety and prevent the spread of fire. Continued on LIC 809-C Continued from LIC 809 KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Additional non-perishable food supplies were observed inside a cabinet adjacent to the kitchen. Inside the cabinet LPA observed a low supply of emergency water, PPE, three (3) 1st aid kits and other dry food supplies. LPA conducted a review of expiration dates on product labels. LPA observed sharps and knives locked in a kitchen drawer. At 10:53 A.M. hot water measured at 115.8 * F. Cleaning supplies are located in separate locked cabinets with additional supplies in the locked garage. Laundry Room: Adjacent to the kitchen, LPA observed a washer and dryer. All cleaning supplies and detergents were locked and inaccessible to residents. Garage: The Garage remains locked and inaccessible to the residents in care. LPA observed extra PPE supplies, cleaning supplies, two (2) refrigerators with extra food for staff and residents, and an office where staff and resident’s files are kept. COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a comfortable temperature of 72 degrees. At 10:50 A.M., during the inspection, the LPA observed an unlocked hallway closet labeled as staff storage. Inside, LPA observed a two (2) drawer nightstand. Inside a drawer LPA observed a bottle of Cyclobenzapr 10MG (muscle relaxer). Facility representative immediately remove prescribed medication and locked it away. LPA observed a working phone available for residents. The LPA observed the required postings in the common area and a fireplace was observed adequately screened. During the inspection, the LPA observed a fire door being improperly held open by a string tied to the doorknob and secured to a metal hook that had been hammered into the wall. The administrator immediately closed the door during today’s visit and acknowledged that the door will remain closed at all times in compliance with fire safety requirements. Continued on LIC 809-C Continued from LIC 809-C BATHROOMS: Bathrooms were observed to be equipped with slip resistant surfaces and grab bars. Between 10:49 A.M. and 11:16 A.M. hot water temperature measured between 105* - 120 *F which was within the required range. BEDROOMS: There are four (5) private bedrooms and one shared bedroom. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. OUTDOOR SPACE: The backyard has a covered patio area, however, no patio furniture was observed during today’s visit. Facility has one side gate; LPA observed the side gate to be self-closing and self-latching gate with clear passageways for emergency exit use. LPA observed a shed located in the backyard, there was mobility devices and boxes with decoration items. Facility provides sufficient space to accommodate both indoor and outdoor activities. There were no bodies of water on the premises. RECORD REVIEW: Between 12:42 P.M. and 2:45 P.M., staff and resident records were reviewed. During the resident’s record review, LPA observed Resident #1 (R1) and Resident #2 (R2) and Resident #4 (R4) to be at risk if allowed direct access to personal grooming and hygiene items. LPA observed R4’s physician report not to have tuberculosis test result. All other records were observed to be complete. Additionally, R1, R2 and R4’s admission agreement did not have the admission date reflected on the main admission contract. Technical violation issued. Furthermore, LPA observed that R1 and R2’s needs and service plan was not updated. Technical Violation issued. During the staff’s record review LPA observed, all files to be complete. However, a comparison of the LIC 500 (Personnel Record) and the Guardian System reflected that Staff #1 (S1) was fingerprinted but not associated to the facility. During today’s visit, facility representative associated S1. LPA requested facility administrator’s file for compliance, however, facility representative was unable to produce it. Continued on LIC 809-C Continued from LIC 809-C INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last drill documented on 04/06/2025. MEDICATION REVIEW: Locked medication cabinet is in the kitchen. Between 2:10 P.M. and 4:10 P.M. Medications for four (4) residents were observed. LPA observed two (2) medications for R1 was centrally stored at the facility, given as prescribed, and logged in the MARS but not logged on the Centrally Store Medication form. Technical Violation issued. Furthermore, LPA observed that R4’s 30-day supply of Famotidine 20MG had a handwritten “opened” date label indication 04/01/2025, written by facility staff. However, the original pharmacy label on the medication container showed a filled date of 11/21/2024. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 16, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Kelly Dulek conducted a pre-licensing visit to this property at 10:12AM. LPA met with applicant representative/facility designee Laila Kulungu. This application is for a Change of Ownership Application (CHOW) and the current licensed facility has residents in care. The applicant has obtained fire clearance for four (4) bedridden, one (1) ambulatory, and one (1) non-ambulatory with a total capacity of six (6) residents. The proposed facility has a pending Dementia care plan. Applicant completed component II interview on 10/06/2023. During today's visit, Facility Designee completed component III with the LPA. Beginning at 10:48AM, LPA inspected the proposed facility for Fire Safety, Personal Accommodations, and Food Service. All hard-wired combination smoke alarm and carbon monoxide detectors were tested at 12:11PM and function properly at this time. Sprinkler system was tested during the fire inspection and functioned properly. Fire extinguisher was observed to be fully charged and purchased on 11/16/2023. Paint, windows, blinds, and floors are in good repair. There are no firearms on the premises. The common living room, den and dining area are clean and properly furnished. A properly screened fireplace was observed in the living room. A working telephone is present. The proposed facility has six (6) bedrooms total and a lanai. Four (4) are private resident rooms, one (1) is a shared resident room and one (1) bedroom and the lanai are designated as staff rooms. All resident bedrooms observed were furnished and contained beds, chairs, bedside tables and lamps. All beds have appropriate linens. There is also an ample supply of linen, towels and paper products. The proposed facility has four (4) bathrooms, one (1) is for shared resident use, one (1) is a private resident restroom, and two (2) are for use by staff and visitors. LPA observed night-lights were present in the hallways. Hot water was measured in the shared restroom and measured higher than the required range. Water temperature was adjusted during the visit and measured just above and at the high end of the appropriate range prior to the end of today's visit. Report Continued on LIC 809-C The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food is present, as well as, a seven-day supply of emergency water. Knives were stored in a locked drawer and cleaning supplies are stored in a locked cabinet under the kitchen sink. A locked medication cabinet was observed in the facility kitchen. First aid kit was observed and was complete. The facility contains a laundry room, containing locked cabinets for chemical storage. A locked garage was observed to contain extra food and storage space, as well as the facility's office. Building and grounds were observed. Patio area contains a shaded seating area for resident use. Outdoor exit gate was observed to be self-closing and self-latching at this time. All passageways were observed to be clear of hazards. The following needs to be corrected prior to licensure: Resident #1 (R1) needs to have their full bed rails removed and replaced with half bed rails. Hot water temperature needs to consistently measure within the required range. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 10, 2024

Type of visit: Office

COMP II by CAB successfully completed Method: Phone Call at CAB Facility Type: RCFE Capacity: Census (if any clients in care): Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Oct 6, 2023