Mondell Pine Manor II

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced visit and was greeted by the staff Renante Cuenca who called the Administrator. House Manager Richard Garcia arrived five (5) minutes later. LPA explained the reason for the visit. The facility is fire cleared for six (6) non-ambulatory residents, two (2) of which may be bedridden. At 12:22 PM, LPA conducted the physical plant tour with the House manager and observed the following: The facility is a single storey with four (4) bedrooms and three (3) bathrooms. An additional bedroom located in the garage was designated for staff use only. Dual smoke and carbon monoxide alarms were tested and observed to be operable. The facility is equipped with sprinkler system. Common Areas – The family room, dining room, and kitchen are combined. The family room was furnished with comfortable seating and a television. The dining room contained a dining room table and chairs. Fire extinguishers were located near the kitchen and the main door upon entry and last inspected on 11/14/25. Medications: LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a kitchen cabinet. Kitchen – LPA observed a two day supply of perishable food and a seven day supply of non-perishable food items. Dishwashing liquid and other cleaning agents were observed locked underneath the kitchen sink. Laundry Room – The laundry room door has a key-punch lock system and was observed to be locked during visit. Laundry detergent and other toxins were locked in the laundry room. (continued from LIC 809) Garage - The garage was attached to the house and can only enter through the locked laundry room. The staff room is located within the garage area. Resident Rooms: There are four resident rooms which were furnished with a bed, linens, night stand, lamp and chair. The rooms were properly furnished and observed to be neat and clean. Bathrooms: There are three bathrooms in the facility. The bathrooms contained hand soap, paper towels, grab bars, and slip resistant mats. LPA observed the clean linens were located in a cabinet within the staff bathroom. Water Temperature: was tested and measured at a range of 107.9°F to 111.8°F. Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. There is a shaded area with comfortable seating in backyard. Client records: Client records are reviewed. Client records appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff record. Staff records appeared to be complete and updated. Disaster drill was last conducted on 01/10/2026. Required posting are observed to be complete and current and displayed properly at the facility. Exit interview conducted. Copy of this report issuedthe state’s words, verbatim · CDSS document, Feb 28, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced case management visit and was greeted by two staff members. LPA Spaeth stated the purpose of the visit was to tour the facility, and review resident and staff records. There are two residents living at the facility. LPA reviewed the resident's files at 10:30 am until 11:00 am LPA Spaeth reviewed the staff files at 11:50 am until 12:00 pm. LPA Spaeth toured the facility at 12:00 pm until 12:15 pm. LPA also observed the staff work schedule and the administrator certificate were posted within the facility. There are no deficiencies to report at this time. Exit interview was conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Jun 26, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced case management visit and was greeted by the facility manager. LPA Spaeth stated the purpose of the visit was to conduct a case management visit. LPA toured the facility and observed a staff member had not been fingerprint cleared. The facility manager confirmed the staff member had been working at the facility for the past two days. The LPA Spaeth spoke to the Licensee, Jerome Viray at 12:45 pm. LPA Spaeth stated to the Administrator the staff member must immediately leave the facility. LPA observed the staff member left the facility at 12:50 pm. Based upon LPA's observations, the following deficiency was issued (see 809-D). Exit interview conducted, appeal rights discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, May 9, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87761(b) · Plan of correction due date: May 9, 2025

87761 Penalties (b)…an immediate penalty of $100 …per day for a maximum of five (5) days shall be assessed if any individual required to be fingerprinted …has not obtained a California clearance or a criminal record exemption… This is evidenced by: The Licensee failed to ensure a staff member had obtained a California Clearance or a criminal record exemption. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 9, 2025

Plan of correction: LPA Spaeth observed the staff member (S1) left the facility.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the staff member. The Administrator Stephanie Domingo was called. LPA stated the purpose of the visit was to conduct an annual inspection. The staff member confirmed there are two residents living in the facility. The facility is licensed for six (6) non-ambulatory residents. Two (2) of the six (6) can be bedridden residents. LPA Spaeth and the staff member toured the facility at 10:15 am until 11:00 am. Common Areas – The family room, dining room, and kitchen are combined. The family room is furnished with comfortable seating and a television. The dining room is furnished with a dining room table and chairs. Medications: LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a kitchen cabinet. Kitchen – LPA observed a two day supply of perishable food and a seven day supply of non-perishable food items. The fire extinguisher is located near the kitchen and was operable. The medications are locked in a cabinet and the knives are locked in a kitchen drawer. Cleaning solutions are locked underneath the kitchen sink. Continued on 809-C Laundry Room – The laundry room door has a key-punch lock system. LPA observed the washer/dryer and the laundry detergent were in the room. Garage –The garage was locked. The staff room is located within the garage area. Resident Rooms: There are four resident rooms which were furnished with a bed, linens, night stand, lamp and chair. The rooms were neat and clean. LPA Spaeth observed the resident rooms contain a sprinkler system. Bathrooms: There are three bathrooms in the facility. The bathrooms contained hand soap, paper towels, grab bars, and slip resistant mats. LPA observed the clean linens were located in a cabinet within the staff bathroom. Water Temperature: LPA tested the water temperature which was 105 degrees F. Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. Comfortable seating is also located in the backyard. Smoke/Carbon Monoxide Detectors: The smoke/carbon monoxide detectors were tested at 11:20 am and were operable. LPA reviewed resident files at 10:45 am until 11:10 am. LPA observed a resident's document was missing from the resident file. LPA reviewed staff's file at 11:20 until 11:30 am. LPA viewed a resident's medication at 11:30 until 11:45 am. Based upon LPA's observations and upon Title 22 Regulations, the following deficiencies are substantiated. (See 809-D page). Exit interview conducted, appeal rights discussed, and a copy of the signed report was given.the state’s words, verbatim · CDSS document, Jan 9, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the caregiver. The Administrator Stephanie Domingo arrived at 10:00 am. LPA stated the purpose of the visit was to conduct an annual inspection. The Administrator confirmed there are five residents living in the facility. The facility is licensed for six (6) non-ambulatory residents. Two (2) of the six (6) can be bedridden residents. LPA Spaeth and the Administrator toured the facility at 10:15 am until 11:00 am.. Common Areas – The family room, dining room, and kitchen are combined. The family room was furnished with comfortable seating and a television. The dining room contained a dining room table and chairs. Medications: LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a kitchen cabinet. Kitchen – LPA observed a two day supply of perishable food and a seven day supply of non-perishable food items. The fire extinguisher was located near the kitchen and was operable. The Administrator opened a kitchen cabinet but observed the lock using a magnet did not properly work. LPA stated to the Administrator that a secure lock will need to be installed. Cleaning solutions were locked underneath the kitchen sink. Laundry Room – The laundry room door has a key-punch lock system. The door was slightly opened and was not securely locked. LPA observed the washer/dryer and the laundry detergent. Continued on 809-C Garage –The garage was locked. The staff room is located within the garage area. Resident Rooms: There are four resident rooms which were furnished with a bed, linens, night stand, lamp and chair. The rooms were neat and clean. LPA Spaeth observed the resident rooms contain a sprinkler system. Bathrooms: There are three bathrooms in the facility. The bathrooms contained hand soap, paper towels, grab bars, and slip resistant mats. At 10:45 am, LPA observed a Lysol spray, cleaning solution stored underneath the bathroom sink and not securely locked. LPA Spaeth tested the water temperature in the bathroom located in a resident's room. The temperature was recorded to be 118.0 Degrees F. LPA observed the clean linens were located in a cabinet within the staff bathroom. Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. Comfortable seating is also located in the backyard. Smoke/Carbon Monoxide Detectors: The smoke/carbon monoxide detectors were tested at 10:55 am and were operable. LPA reviewed resident files at 11:00 am until 11:50 am. LPA Spaeth observed resident 1 and resident 5 did not contain the Physician's Report. LPA reviewed staff records at 11:50 am until 12:20 pm. LPA viewed a resident's medication at 12:20 until 12:30 pm. Based upon LPA's observations and based upon Title 22 Regulations, the following deficiencies are substantiated. (See 809-D page). Exit interview conducted, appeal rights discussed, and a copy of the signed report was given.the state’s words, verbatim · CDSS document, Feb 23, 2024