Mom's Place I

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 12:30 P.M. Upon arrival, the LPA knocked on the door; however, there was no response. 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: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:15 A.M. The LPA was greeted by Caregiver Romeo Thompson. LPA informed the reason for the visit. Caregiver contacted the facility representative by phone, Laila Kulungu. At 10:55 A.M. facility representative arrived. Administrator, Yusuf Ibironke, was unavailable during today's visit and does not come to the facility often due to distance, however, authorized facility representative, to sign today's reports. Reason for the visit was stated. Entrance interview conducted. At 11:10 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 purchased 04/16/2025. Between 11:32 A.M. and 11:39 A.M. two (2) carbon monoxide detectors and the hardwired smoke detectors were tested and functioned properly. According to facility representative, the door connecting the common area to the wing where rooms one (1) through four (4) are located is designated as a fire door. This door is in place to enhance safety and prevent the spread of fire. Continued on LIC 809-C Continued from LIC 809-C 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. LPA conducted a review of expiration dates on product labels. LPA observed sharps and knives locked in a kitchen drawer. At 11:20 A.M. hot water measured at 117.2 * F. 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. 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 held open by a magnet; however, when the smoke detectors were tested, the fire door did not release and close as expected. The administrator immediately closed the door during today’s visit and acknowledged that the door will be maintained closed at all times or the wiring connecting the fire door to the smoke alarms should function properly in the event of a fire to be in compliance with fire safety requirements. Cleaning supplies are located in a separate cabinet next to the main entrance. LPA observed the door to be secured with a deadbolt lock which does not requires a key to unlock. Per facility’s representative, a handyman is scheduled to install a keyed entry deadbolt. BATHROOMS: There are two and a half (2 1/2) shared restrooms in the facility. All restrooms were observed to be clean and sanitary and in operating condition. Showers were also observed to have grab bars and slip resistant mats and surfaces with sufficient amounts of soap and paper products in each restroom. The LPA observed low pressure from the faucet located in the bathroom of room #3, as well a broken toilet paper dispenser in the hallway’s shared bathroom. Water temperature was measured in all shared restrooms and measured within the required range. Continued on LIC 809-C Continued from LIC809-C BEDROOMS: The facility has five (5) bedrooms total; one bedroom is shared, and the rest are private. The den is used as a staff room and remains locked. 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. LPA observed a broken electrical outlet in vacant room #5, also, Resident #1(R1), a hospice recipient, had full rails on their bed. LAUNDRY ROOM: The facility's laundry room is connected to the home but only accessible from outside. Laundry supplies are kept inside the locked closet in the house. GARAGE: The Garage remains locked and inaccessible to the residents in care. LPA observed extra PPE supplies, cleaning supplies, a refrigerator with extra food for staff and residents and mobility devices. OUTDOOR SPACE: The backyard has a covered patio which had shade and seating areas for residents to enjoy. Facility has three (3) side gates. LPA observed all gates to be self-closing and self-latching gates with clear passageways for emergency exit use. Facility provides sufficient space to accommodate both indoor and outdoor activities. There were no bodies of water on the premises at the time of the visit. RECORD REVIEW: Between 12:45 P.M. and 2:17 P.M., staff and resident records were reviewed. During the resident’s record review, LPA observed Resident #1 (R1) to be at risk if allowed direct access to personal grooming and hygiene items. All other records were observed to be complete. However, all residents were missing authorized representative’s signatures on their Needs and Service Plan. During the staff’s record review LPA observed, all files to be complete. LPA requested facility administrator’s file for compliance, however, facility representative was unable to produce it. According to our records, administrator’s certificated expired on 01/16/2025 and no renewal applications have been received at this time. Licensee is working to get a new administrator assigned to this facility. Additionally, 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, Licensee associated S1. Continued on LIC809-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 dining room and the kitchen. Between 2:10 P.M. and 3:20 P.M. Medications for four (4) residents were observed. LPA observed prescribed medications for Resident #2 (R2) -Bumetanide 2MG Tablet (16qty)- to be taken twice a daily. The Centrally Stored Medication Log indicates a start as of 05/01/2025. However, medication count in the bubble pack did not match the expected quantity bases on the prescribed dosage and start date. 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, May 19, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Teresa Camara conducted an announced pre-licensing visit to this property at 1:30 p.m. 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 six residents in care. The applicant has obtained fire clearance for a total capacity of six non-ambulatory residents, one of which may be bedridden. The pending facility has a Dementia care plan. Applicant completed the component II interview on 09/21/2023. During today's visit, the facility designee completed component III with the LPA. Beginning at 1:35 p.m., 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 and function properly. Sprinkler system was tested during the fire inspection on 4/11/2024 and functioned properly. Fire extinguisher was observed to be fully charged and purchased on 11/10/2023. Paint, windows, blinds, and floors are in good repair. There are no firearms on the premises. The living room and dining area are clean and properly furnished. A properly screened two-sided fireplace was observed in the dining room and living room. A working telephone is present. The proposed facility has five (5) bedrooms total; one bedroom is shared and the rest are private. The den is used as a staff room and remains locked. 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. LPA observed each bathroom has a mirror which also serves as a night light. Hot water temperature was measured in the kitchen and all bathrooms and ranged between 106.6*F - 107.7*F. . (continued on LIC809-C) (continued from LIC809) The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food is present; stored in the kitchen and detached garage. An emergency supply of water was also present in the garage. Knives were stored in a locked drawer and cleaning supplies are stored in a locked cabinet under the kitchen sink. Additional cleaning supplies are locked in the closet near the front door entryway. A locked medication cabinet was observed in the dining room. First aid kits were observed in the medication cabinet. The facility's laundry room is connected to the home but only accessible from outside. Laundry supplies are kept inside the locked closet in the house. 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. Pre-Licensing is complete and this facility has no deficiencies. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 13, 2024

Type of visit: Office

An office meeting was conducted at the Woodland Hills North Adult and Senior Care Regional Office (RO). The purpose of today’s meeting was to discuss the license applications pending as well as the Licensee’s newly-licensed facilities within the RO’s jurisdiction. Present at today’s meeting were: Oyewole (Joseph) Jose, Licensee, Jill Nakata, Regional Manager (RM), KaSandra Lopez, Licensing Program Manager (LPM), and Kelly Dulek, Licensing Program Analyst (LPA). Additionally, telephonically present were: Kristin Heffernan, Licensing Program Manager (LPM) and Desaree Perera, Licensing Program Manager (LPM). The Licensee is responsible for the following currently licensed facilities: Clarendon Senior Living 2, Clarendon Senior Living 3, Mali’s Place I, Mali’s Place II, Omnicare, Omnicare II, and Sunshine Residential Home Balboa. The Licensee is also responsible for the following pending applications: Mom’s Place 2, Mom’s Place 3, Mom’s Place I, Omnicare III, Sally’s Residential Care Home, Sally’s Residential Care Home 2, Sally’s Residential Care Home 3, and Sally’s Residential Care Home 4. There are an additional 15 facilities, both pending and currently licensed, outside this RO’s jurisdiction the Licensee is responsible for. During today’s meeting, RM, LPM, and LPA discussed the following topics: · Construction plans/physical plant concerns and the corresponding communication with CCL and residents/responsible parties. RM reminded licensee to ensure proper construction permits are obtained. · Communication with CCLD – RO and Centralized Application Bureau (CAB) · Administrator plan for the Licensee’s facilities - Licensee previously provided LPA with 3 (three) potential Administrators, 2 (two) of which have pending Administrator Certificates. RO will follow up with Administrator Certification section. · Spreading thin of the Licensee. Ensure Management team is in place to support the growth of the business. · LLCs listed as the Licensee – one shows as inactive. Clarification on which LLCs should be listed. Report Continued on LIC 809-C Managing members of the corporations, a plan to ensure continuity/backup in case of emergency. · Change of Ownership applications and Interim Management Agreements for pending applications. The Licensee discussed: · The construction contract with the current contractor included measures to keep the residents safe, but that doesn't appear to be what has happened. Licensee will stop work immediately and revisit when there is a relocation site to ensure health and safety of the residents in care. · Joseph had an agreement with the current licensees for them to continue to manage operations for their facilities until they closed escrow and the current licensees changed the plan. · Administrators had to renew or apply for new certificates, which is taking a lot of time to process. · 12 Admins on his team at this point and a day program director. 30 total facilities licensed and/or pending at this point. · Currently, Joseph Jose is the only managing member of the LLCs currently, but that will change. Joseph understands over majority change, needs to go through CAB. Have a lot of RCFEs that can use a management company and Joseph is aware of how to add a management company to the License. · Joseph met with CAB supervisors this summer – he asked to have just 1 or 2 analysts looking at the applications would be helpful to streamline the process. · Joseph discussed transparency with both the Department and families and ensuring best practices for communication going forward. The following documents were provided to the Licensee: Health and Safety code 1569.191 related to sale of licensed facilities. Reporting requirements and the documents needed to change an Administrator. Copies of the LIC 308 and LIC 500 Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 30, 2023