Nagomi Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vaid conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Administrator Tokie Ayabe and explained reason for visit. This facility is a Residential Care for Elderly and is licensed to serve six (6) non-ambulatory elderly residents, ages 60 and above in rooms A, C, and D. One (1) bedridden is approved in room B. Hospice waiver approved for five (5) residents. Annual licensing fees are current. The facility consists of a two-story building. First floor had five (5) resident rooms, living room, kitchen, dining area and four (4) resident bathrooms. Second floor consisted of four (4) staff rooms and two (2) staff bathrooms. All resident bedrooms were toured. Each bedroom has a bed, linen, dresser, and lighting. Smoke detectors/carbon monoxide detectors were observed in each room and throughout facility. The facility has one (1) fire extinguisher that is fully charged in kitchen, 07/24/2025. LPA observed cleaning supplies and toxic substances locked in hallway closet. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed in the kitchen. The resident bathrooms have the required grabs bars and non-skid mats. The hot water temperature in the bathrooms was measured between the required range of 105-120 degrees F. The common areas include the living room and dining area, are clean and have the required furniture. The facility does not have a swimming pool or large body of water. There are no firearms or weapons stored at the facility. There is a shaded seating area for the residents in back yard. Passageways and exits are free of obstruction. There is a shaded seating area in backyard. CONTINUED ON 809C................. Three (3) staff files were reviewed staff have the required certifications for CPR and First Aid, training is on-going and continuous. Five (5) resident files were reviewed and included physicians report, TB clearance, and appraisal needs and service plans. Last fire/earthquake drill was conducted in 04/01/2026. Infectious control plan was reviewed. Disaster plan was reviewed. Administrator certificate expires 05/27/2027. Two (2) staff and three (3) residents were interviewed. Resident medications were reviewed, medications are centrally stored and locked MAR log is used and no discrepancies found. Liability insurance expires 07/13/2026. Administrator to provide liability Insurance for RCFE via email. Zero (0) deficiencies were observed and cited per California Code of Regulations, Title 22. An exit interview was conducted. This report was discussed and provided to Administrator, Tokie Ayabe.the state’s words, verbatim · CDSS document, Jun 1, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Administrator Tokie Ayabe at approximately 8:00AM and explained reason for visit. This facility is a Residential Care for Elderly (RCFE). Facility is licensed to serve six (6) non-ambulatory elderly residents, ages 60 and above in rooms A, C, and D. One (1) bedridden is approved in room B. Hospice waiver approved for five (5) residents. Annual licensing fees are current. The facility was a two-story building. First floor had five (5) resident rooms, living room, kitchen, dining area and four (4) resident bathrooms. Second floor consisted of four (4) staff rooms and two (2) staff bathrooms. Administrator will submit updated facility sketch for bedroom E. Administrator did not have a plan of operation and a dementia plan available at time of visit. All resident bedrooms were toured. Each bedroom has a bed, linen, dresser, and lighting. Administrator will obtain physicians orders for all resident bed rails. Smoke detectors/carbon monoxide detectors were observed in each room and throughout facility. The facility has one (1) fire extinguisher that is fully charged in kitchen. LPA observed cleaning supplies and toxic substances under bathroom #1 sink and in unlocked hallway closet. LPA observed two pairs of scissors in two kitchen drawers at time of visit. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There are no firearms or weapons stored at the facility The resident bathrooms have the required grabs bars and non-skid mats. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The common areas include the living room and dining area are clean and have the required furniture. The facility does not have a swimming pool or large body of water. There is a shaded seating area for the residents in back yard. Passageways and exits are free of obstruction. There is a shaded seating area in backyard. Four (4) staff files were reviewed and two (2) were missing health screening with TB. Six (6) resident files were reviewed and included physicians report, TB clearance, and appraisal needs and service plans. Last fire/earthquake drill was conducted in April of 2025. Infectious control plan was reviewed. One (1) staff and two (2) residents were interviewed. Resident medications were reviewed, and no discrepancies found. Medications are centrally stored and locked MAR log is used. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, May 13, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Administrator, Tokie Ayabe, who assisted with the visit. Facility is licensed to serve six (6) non-ambulatory elderly residents, ages 60 and above. Hospice waiver approved for two (2) residents. Annual licensing fees are current. During the visit, CARE tool was used, a tour of the facility was conducted, food supply/medication were reviewed, staff/residents were interviewed and staff/residents records were reviewed. The facility was a two-story building. First floor had four (4) resident rooms, office, activity room, living room, laundry area, kitchen, four (4) resident bathrooms, and dining room. Second floor consisted of four (4) staff rooms and two (2) staff bathrooms. All the rooms were furnished with appropriate furniture for residents’ comfort. The bathrooms were furnished with grab bars and nonskid surfaces. Common areas were observed for the ability to safely serve the needs of the residents. Hot water temperature was 116.4 degrees Fahrenheit. Adequate linen and personal hygiene supplies were observed. No pools and bodies of water on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely. Sufficient supplies of perishable and nonperishable foods were observed. Knives, tools, sharp items were inaccessible to residents. Smoke detectors and carbon monoxide detectors were operable. Fire extinguishers were fully charged. Medication, residents’/ staff’s records were centrally stored in a locked cabinet and inaccessible to residents. Toxic substances were inaccessible to residents. Administrator certificate is current and expiring on 5/27/25. No deficiencies were observed and cited per California Code of Regulations, Title 22. An exit interview was conducted. This report was discussed and provided to Administrator, Tokiethe state’s words, verbatim · CDSS document, Jul 9, 2024

Type of visit: Case Management - Health Checks

Licensing Program Analysts (LPAs) Tao and Reyes conducted an unannounced initial case management visit regarding a Health and Safety check of the facility regarding a hospice resident#1 (R1). LPAs met with Administrator, Tokie and explained the reason of the visit. According to the incident report dated 3/7/24, R1 admitted to hospice on 9/3/23 and became bedridden on 3/6/24. Per investigation, Hospice stated R1 is bed bounded and the life expectance is less than 14 days. Administrator had contacted fire department for a fire watch during this period of time. During today's visit, LPA interviewed administrator, R1's file was reviewed and obtained the following: · Staff roster and resident roster · Resident #1 (R1) facesheet dated 04/25/23 · Unusual incident report, dated 03/07/24 · Physicians report R1- R6 · R1's Vitas Healthcare plan of care, dated 3/8/24 · R1's Hospice Care Vita Information · R1's Admission agreement. Administrator stated she provide updates about R1 via incident report / death report. Exit interview was conducted and a copy of LIC 809 Report was provided to administrator.the state’s words, verbatim · CDSS document, Mar 8, 2024