Navita Residences Edgemont

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:45 A.M. The LPA was greeted by Caregiver, Maryanti FNU, and informed of the reason for the visit. Caregiver contacted the Administrator by phone, Shila Pandey. At 10:38 A.M. the Administrator arrived at the facility. LPA explained the reason for the visit. Entrance interview conducted. Beginning at 11:00 A.M., the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Hardwired smoke detectors and Carbon Monoxide detectors were tested at 1:30 P.M. and were functional at the time of the visit. LPA observed one (1) fire extinguisher throughout the facility. The purchase date was missing; however, Administrator provided a receipt with 10/28/2024 as the purchase date. LPA explained to the Administrator that the fire extinguishers is required to be serviced annually to ensure it remains fully charged and in proper working condition. The Administrator acknowledged the requirements and agreed to service or replace the fire extinguisher annually and maintain proof of purchase or service attached to the equipment. Continued on LIC 809-C Continued from LIC 809 BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 7 (seven) bedrooms in total; 1 (one) of which is designated as a staff room and 6 (six) are private resident rooms. LPA observed three (3) residents’ beds equipped with bedrails that extended the entire length of the bed. Currently no residents in care are receiving Hospice services. Administrator stated they were aware that full-length bed rails are only permitted for residents receiving hospice services. However, the Administrator stated that they were kept in place to prevent residents from falling out of bed. Full rails were removed during today’s visit. Technical Violation (TV) issued. Staff room was observed locked. RESTROOMS: The LPA observed 3 (three) restrooms in the facility; 2 (two) are shared restrooms and one is a private restroom. Resident restrooms are sanitary and in operating condition with grab bars and slip-resistant surfaces. Water temperature was measured in all bathrooms and measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit. COMMON SPACES: When LPA arrived at the facility, the LPA observed the fire door was prompt opened with a black rubber door stopper. In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be adequately screened and inaccessible to residents. Auditorial signals were observed in each door around the facility. The facility maintained a temperature of 70 degrees Fahrenheit. OUTDOOR SPACE: The backyard has a shaded seating area for residents to enjoy. The facility has one (1) side gate. The gate was observed to be self-closing and self-latching. The LPA did not observe any obstructions to emergency exit pathways. The garage is attached to the house and locked at all times. Garage contained the laundry area, extra food, emergency water and additional mobility devices. Cleaning supplies and chemicals are stored and inaccessible to residents. Continued on LIC 809-C Continued fromLIC 809-C KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food, as well as emergency food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. At 11:45 A.M., hot water temperature measured 108.5 degrees Fahrenheit. RECORD REVIEW: Record review began at 12:00 P.M., records were reviewed for but not limited to: health screening, TB test, staff training records, CPR certificate, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All records were in compliance with regulations. LPA reviewed five (5) staff files including the administrator’s file. LPA observed that the Administrator and Staff #1’s (S1’s) CPR certificate expired. Technical Assistance (TA) was issued. MEDICATION REVIEW: Medications were observed locked in a cabinet across from the kitchen. Review began at 1:50 P.M. Medications for three (3) residents were observed. During the medication audit, LPA observed discrepancies for three (3) residents. The medication count on hand did not correspond with the documented medication start/open date and prescribed directions. For example, Resident #1 (R1) had a Metropolol bottle containing 25 pills remaining out of an original 90-count prescription. The medication directions indicated one pill per day; however, the documented open/start date was 09/2025. LPA requested the following documentation, Personnel Record (LIC 500), Resident Roster (LIC 9020), and current liability insurance. Last emergency disaster drill was conducted on 06/30/2026. Additionally, LPA observed that the Infection Control Plan was not reviewed and/or updated annually, as required. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). One (1) civil penalty was issued, totaling $500. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 18, 2026

Allegation investigated: Licensee is restricting residents' visitations

This report has been amended to remove confidential information. Licensing Program Analyst (LPA) Valeria Conway conducted an unannaunced 10-day initial complaint visit to address the allegation listed above. LPA arrived at 10:15 A.M. and met with Licensee Shila Pandey. Entrance interview conducted. During today’s visit, the LPA conducted a brief plant tour to ensure there are no health and safety concerns. Between 10:45 A.M. and 1:30 P.M., the LPA conducted in-person interviews with the Administrator, staff, residents, and a hospice social worker, and completed a telephone interview with the facility’s designee. In addition, the LPA reviewed resident files and obtained copies of relevant documentation pertaining to the investigation. Based on the information gathered, the following was then determined: Continued from LIC 9099-C Substantiated Continued from LIC 9099 Regarding the allegation “Licensee is restricting residents' visitations”, it was reported that the facility is restricting visitations for a certain individual and requesting they obtain prior permission to visit residents. Information gathered during the course of the investigation revealed that the individual has a prior affiliation with the facility and that management informed all staff that the individual was not welcomed at the facility and not allowed entry. Interviews conducted with residents reflected the fact that they enjoy the visits from this individual, noting that they participate in activities together and listen to music. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Licensee is restricting residents' visitations” has been SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-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, Dec 5, 2025 · control 29-AS-20251203105050

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Dec 19, 2025

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (11) To have their visitors... permitted to visit privately during reasonable hours and without prior notice... This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when requeted RP to ask for permission prior to visiting residents in care, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2025

Plan of correction: Licensee agreed to review section cited, including all staff members, and provide a written plan on how they will ensure future compliance with the regulation and provide document to LPA via email by POC due date.

Allegation investigated: Staff do not treat resident with dignity or respect

Licensing Program Analyst (LPA) Valeria Conway conducted a 10-day initial complaint visit to address the allegations listed above. LPA arrived at 9:40 A.M. and met with facility staff, Mis “Nana” Sunariyati, who contacted via telephone facility administrator. At 10:15 A.M. Facility Designee Karthiga (Karthi) Vijayakumar and Administrator, Shila Pandey arrived at the facility. Entrance interview conducted. During today’s visit, the LPA conducted a brief plant tour at 10:20 A.M. to ensure there are no health and safety concerns, conducted interviews with the Administrator and facility designee, two (2) staff members, and three (3) residents. Between 10:00 A.M. and 2:30 P.M., conducted a resident file review, and obtained copies of pertinent documents relevant to the investigation. The following was then determined: Continued on LIC 9099-C Substantiated Continued on LIC 9099 Regarding the allegation that "Staff did not ensure that resident's grooming needs were met", the reporting party (RP) expressed concern that residents are not being kept groomed. During today’s visit, LPA inspected all residents’ rooms and did not detect any foul odors. An interview with a visiting nurse revealed that they have not observed the resident under their care to be unkempt or inadequately groomed. In addition, LPA interviewed four (4) out of five (5) residents and observed their nails, hair, and clothing. LPA did not observe any residents to be unkempt. One (1) resident stated that staff occasionally forget to shave them; however, when they request assistance with shaving, staff complete the task without issue. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Staff did not ensure that resident's grooming needs were met” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report provided. Continued from LIC 9099 Regarding the allegation that “Staff does not treat resident with dignity or respect”, the reporting party expressed concern that Staff #1 (S1) yelled at residents in care and handled them in a rough manner. Staff interviewed denied these allegations and stated that they treat all residents with respect. However, interviews with residents indicated that on some occasions S1 may have handled residents roughly while providing incontinence care or changing them. Residents also reported witnessing staff raise their voices when residents were “not being cooperative”. Additionally, R1 informed LPA that staff turn off their television at 8:00 P.M. every night and take the remote control until the following morning. R1 further stated that when the television is turned off and they are unable to sleep, they would prefer to listen to music, but staff keep their radios away from them. According to R1, staff do this, so neither the radio nor the television disturb other residents. LPA observed R1’s room and observed their radio on the floor face down and out of R1’s reach. The administrator stated that R1’s family authorized staff to keep the television remote controls secured because R1 will otherwise remain awake throughout the night Per administrator, when resident doesn't rest it results in health issues the following day. During today’s visit, LPA observed a resident requesting assistance from a staff member. The staff member responded in an unfriendly manner, stating “I am busy”, and walked away without providing assistance. LPA explained to the administrator the importance of using alternative approaches when a staff member is occupied, to ensure residents are addressed respectfully and their needs are acknowledged. LPA requested the most recent in-service training records regarding residents’ personal rights. The administrator provided documentation of the training, however, during interviews, staff stated that they had not received this training. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “ “Staff does not treat resident with dignity or respect”, has been SUBSTANTIATED at this time. 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, Nov 14, 2025 · control 29-AS-20251107111518

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Nov 25, 2025

87468.1 Personal Rights of Residents in All Facilities (a) (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interview, residents report staff occasionally handled them rough and occasionally yelling at the residents, which poses an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 14, 2025

Plan of correction: Administrator will hire a third-party service to train staff on personal rights and dementia and submit proof of training to CCL before POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Valeria Conway conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20251107111518). LPA arrived at 9:40 A.M. and met with facility staff, Mis “Nana” Sunariyati, who contacted via telephone facility administrator. At 10:15 A.M. Facility Designee Karthiga (Karthi) Vijayakumar and Administrator, Shila Pandey arrived at the facility. The purpose of the report is to issue citations for deficiencies observed during the initial complaint investigation. Entrance interview conducted. During today’s visit, the LPA conducted a brief plant tour at 10:20 A.M. to ensure there are no health and safety concerns, conducted interviews with the Administrator and facility designee, two (2) staff members, and three (3) residents between 10:00 A.M. and 1:30 P.M., conducted a resident file review, and obtained copies of relevant documents. During the course of the investigation, LPA requested Resident’s #1 (R1’s) file. LPA observed that R1 was admitted in January 2024 and that the facility completed an appraisal/needs and service plan in August 2024. The need and services plan for 2025 was observed to be a duplicate of the 2024 document, with the only difference being that the last page was dated 8/11/2025. LPA further observed that the facility indicted progress notes were used as a method of evaluating the resident’s progress, however, when the LPA requested these notes, the administrator stated that neither management nor staff are keeping progress notes and that the forms need to be revised and completed accurately. Continued on LIC 809-C Continued from LIC 809 Additionally, at approximately 1:25 P.M., LPA interviewed Resident #2 (R2) in their room. During the interview, the LPA observed R2 seated in a recliner chair and noted that there was no bed in the room. R2 stated that they prefer to sleep in the recliner and do not wish to use a bed. While on site, a family member of R2 arrived and informed LPA that this has been R2’s long-standing preference and that they have slept in a recliner for many years. LPA revied R2’s physician’s report, which indicated that R2 must use a medical recliner to sleep. LPA asked the administrator whether an exception request had been submitted to the Department; however, the administrator confirmed that an exception had not been submitted. 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, Nov 14, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(i) · Plan of correction due date: Nov 26, 2025

(i) When there is significant change in condition... or once every 12 months, whichever occurs first, the licensee shall arrange an in-person... to share the reappraisal with the resident, the resident's representative... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by having R1's appraisal/needs and services plans not updated which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 14, 2025

Plan of correction: Administrator will assess the resident and complete a new needs and services plan for R1 and submit new needs and service plan to LPA before POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(a)(3)(A) · Plan of correction due date: Nov 26, 2025

(A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by not applying for an exception for resident 2, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 14, 2025

Plan of correction: Administrator agreed to submit an exception for R2 before POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:08 A.M. The LPA was greeted by Caregiver Ari Lutfi Mahendra and informed the reason for the visit. Caregiver contacted the Administrator by phone, Shila Pandey. At 10:25 A.M. the Administrator arrived at the facility. At 10:38 A.M., the back-up Administrator, Karthiga Vijayakumar joined the visit. LPA explained the reason for the visit. Entrance interview conducted. Beginning at 10:48 A.M., the LPA along with the Administrator and back-up Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Hardwired smoke detector and Carbon Monoxide detectors were tested at 11:41 A.M. and were functional at the time of the visit. LPA observed one (1) fully charged fire extinguisher purchased on 10/28/2024. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 7 (seven) bedrooms in total; 1 (one) of which is designated as a staff room and 6 (six) are private resident rooms. Staff room was observed locked. There were no visible hazards or discrepancies observed. RESTROOMS: The LPA observed 3 (three) restrooms in the facility; 2 (two) are shared restrooms and one is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Water temperature were measured in all bathrooms and measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit. Continued on LIC 809-C Continued from LIC 809 COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be adequately screened and inaccessible to residents. Auditorial signals were observed in each door around the facility. The facility maintained a comfortable temperature of 68 degrees Fahrenheit. OUTDOOR SPACE: The backyard has a shaded seating area for residents to enjoy. The facility has one (1) side gate. The gate was observed to be self-closing and self-latching. The LPA did not observe any obstructions to emergency exit pathways. The garage is attached to the house and locked at all times. Garage contained the laundry area, extra food, emergency water and additional mobility devices. Cleaning supplies and chemicals are stored and inaccessible to residents. Emergency water is stored in the garage. KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food, as well as emergency food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. At 11:20 A.M., hot water temperature measured 114.8 degrees Fahrenheit. RECORD REVIEW: Record review began at 11:54 A.M., records were reviewed for but not limited to: health screening, TB test, staff training records, CPR certificate, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All records were in compliance with regulations. LPA reviewed four (4) staff files including the administrator’s file; all four (4) files reviewed were complete. MEDICATION REVIEW: Medications were observed locked in a cabinet across from the kitchen. The review began at 1:45 P.M. Medications for 4 (four) residents were observed. All residents' medications were observed to be maintained and administered in compliance with regulation. LPA requested the following documentation, Personnel Record (LIC 500), Resident Roster (LIC 9020), and current liability insurance. Last emergency disaster drill was conducted on 06/30/2025. Additionally, LPA observed emergency disaster plan to be complete and updated annually, as required. Facility has procedures in place regarding the infection control plan; however, the LIC 9282, as required by the department was not available for review. Technical Violation (TV) issued. Exit interview conducted. No deficiencies cited. A copy of the report was provided to the Administrator.the state’s words, verbatim · CDSS document, Aug 20, 2025

Allegation investigated: Staff do not properly maintain the kitchen area Staff are not providing adequate supervision to the residents Resident is locked inside their bedroom Staff are unable to communicate effectively Facility is not maintained in a clean and safe condition Staff are not providing adequate food service to a resident Staff do not meet resident's incontinence needs

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint visit to address the allegations listed above. LPA arrived at 12:37PM and met with Facility Designee Karthiga (Karthi) Vijayakumar. Entrance interview conducted. During today’s visit, LPA interviewed facility designee at 12:43PM, conducted a facility tour with facility designee at 01:00PM, and LPA interviewed staff and residents between 01:10PM and 02:25PM. During an initial complaint visit, conducted on 08/02/2023, LPA interviewed Administrator at 10:30AM, residents at 10:26AM, 11:03AM, and 05:27PM. LPA toured the facility along with Administrator at 10:46AM and took photographs during the tour. LPA reviewed and obtained copies of documents pertinent to the visit. Throughout the course of the investigation, LPA reviewed all documents and photographs taken. The following was then determined: Report Continued on LIC 9099-C (p.2) Unsubstantiated Allegation: “Staff do not properly maintain the kitchen area:” The reporting party indicated that during a recent visit at the facility, the kitchen area was observed to have sticky floors and the refrigerator handle had food particles on it. The visit occurred beginning around 05:00PM and the facility staff told the reporting party that they were in the middle of cleaning, as the residents finished dinner. During the initial complaint visit, LPA observed the kitchen to be clean and without any noticeable food residue observed in the kitchen. The LPA noted staff present in the kitchen cooking upon arrival to the facility, however, the kitchen was clean. Staff interviewed stated that there is a resident who comes into the open kitchen often, but that resident is redirected. During the subsequent complaint visit, as LPA approached the front door, LPA observed staff cleaning up the kitchen area following lunchtime. The kitchen was observed to be clean and hazard free. Staff interviewed indicated that after the residents’ needs are met after meals, they clean up the kitchen area, as well as cleaning up while cooking and preparing meals. Based on observation and interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “staff do not properly maintain the kitchen area” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff are not providing adequate supervision to the residents:” The reporting party indicated that the hallway door was closed during their recent visit at the facility and when the reporting party asked the staff how they would be able to hear the residents residing in those rooms, the caregiver did not provide an adequate response. LPA observed during the initial complaint visit that the door the reporting party was concerned with is a fire door, as thus, the door is required to remain closed at all times for the safety of the residents. Upon arrival at the initial visit, LPA observed the door to be propped open. LPA issued a citation related to fire clearance as a part of the concurrent annual visit. Staff then closed the door and it remained closed for the duration of the visit. LPA observed staff walking about the facility and opening the door to check on residents throughout the visit. Residents interviewed felt their needs were met, staff are accessible when needed and that there is adequate supervision. LPA did not note any concerns related to supervision on either the initial or subsequent complaint visits. Based on interview and observation, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “staff are not providing adequate supervision to the residents” is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C (p.3) Allegation: “Resident is locked inside their bedroom:” The complaint alleges that the door to Resident #1 (R1)’s bedroom has a lock which does not have a key and that the resident is locked inside their room to prevent wandering behavior. LPA interviewed staff and R1. Staff did indicate that R1 has wandering behavior and that R1’s door does have a lock on their door for privacy. Staff interviewed stated R1 locks the door, not the staff and that R1 is able to enter and exit their private room without assistance. During the initial complaint visit, LPA spoke with R1 who confirmed they have a lock on their door. LPA observed R1 inside their room. R1 was able to both engage and disengage the lock, as they desire, and R1 was able to exit their room without assistance. Based on interview and observation, at this time, there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “resident is locked inside their bedroom” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff are unable to communicate effectively:” The reporting party indicated there is a language barrier between the staff and the reporting party and that staff did not understand what the reporting party was trying to convey. LPA Dulek spoke with staff both informally and formally during both the initial complaint visit and the subsequent complaint visit. Another LPA also recently conducted an unrelated visit. Neither LPA noted concerns related to communicating with the staff. Residents interviewed indicated that the staff understand and are able to communicate with residents with basic English. Based on interview and observation, there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “staff are unable to communicate effectively” is deemed UNSUBSTANTIATED at this time. Allegation: “Facility is not maintained in a clean and safe condition:” The complaint alleges that there is water dripping from a vent located in the front entry leading to the kitchen area, which is causing a slip and fall hazard in the facility. During the initial visit, LPA did not observe any water leaking. At the subsequent complaint visit, LPA did note some condensation on the vent, however there were no drips and no water on the ground underneath the vent during either visit. LPA advised the Facility Designee to be aware of the vent gathering condensation. LPA did note that both the initial complaint visit and the subsequent complaint visit were conducted at times when the weather was very warm outside and the air conditioning was running frequently. During the visit, Facility Designee informed the Administrator Report Continued on LIC 9099-C (p.4) of the potential for water dripping from the vent and maintenance will be out to assess the vent. Facility was observed to be clean and no immediate health and safety hazards were observed during either complaint visit. Residents interviewed indicated they have not observed any safety hazards and the facility is cleaned sufficiently to meet their needs. Based on interview and observation, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “facility is not maintained in a clean and safe condition” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff are not providing adequate food service to a resident:” LPA observed food served and food present in the facility during both the initial and subsequent complaint visits. There was sufficient amount of food present to meet the minimum 2 days perishable and 7 days non perishable in all food groups during both visits. LPA observed soup and sandwiches served during lunch time. Residents interviewed indicated that food is varied and they are happy with the food served at the facility. Snacks are available as well as regular meals. Staff stated that meals consist of proteins, vegetables, fruit and milk is offered to the residents also. Based on observation and interview, there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “staff are not providing adequate food service to a resident” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff do not meet resident's incontinence needs:” The complaint alleges that incontinence odors were present upon a visit to the facility. The reporting party instructed the staff to check and change a resident’s incontinence brief, which staff completed, but indicated the resident was dry. However, the reporting party indicated the odor persisted. During both the initial and subsequent complaint visit, LPA did not encounter any evidence of incontinence odors. Residents interviewed indicated they are changed at least 3 times a day, if not more as needed. Residents stated their incontinence needs are met. Staff interviewed indicated they check the residents every 1-2 hours and that residents are changed whenever they are observed to be wet during their checks. Residents are showered at least twice a week, if not more as needed based on each resident’s incontinence needs. Based on interview and observation, there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “staff do not meet resident’s incontinence needs” is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted with Facility Designee. A copy of today’s report was provided.the state’s words, verbatim · CDSS document, Oct 4, 2024 · control 29-AS-20230731161300

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:00 A.M. The LPA was greeted by Caregiver Charlin Sitompul and informed the reason for the visit. Caregiver contacted the Administrator by phone, Shila Pandey. At 9:50 A.M. Administrator arrived at the facility, LPA explained the reason for the visit. Entrance interview conducted. Beginning at 10:25 A.M., the LPA along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Combination smoke and Carbon Monoxide detector was tested at 11:14 A.M. and was functional at the time of the visit. LPA observed one (1) fully charged fire extinguisher purchased on 03/21/2023. Administrator will buy a replacement and send proof to LPA. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 7 (seven) total bedrooms; 1 (one) of which is designated as a staff room and 6 (six) are private resident rooms. Staff room was observed locked. No client bedroom will be used as a public or general passageway to another room, bath, or toilet. There were no visible hazards or discrepancies observed. LPA observed that facility is not using appropriate waste receptacle with a tight-fitted cover. RESTROOMS: The LPA observed 3 (three) restrooms in the facility; 2 (two) are shared restrooms and one is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperatures were measured in all client bathrooms and measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit. Continues on LIC 809-C Continued from LIC 809 COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be adequately screened and inaccessible to residents. Auditorial signal was observed in each door around the facility. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Facility has a fire door to contain a fire from one side of the house to the other side. At the time and during the visit fire door was always open. OUTDOOR SPACE: The backyard has a shaded seating area for resident use. There were no bodies of water noted. The garage is attached to the house and locked at all times. Garage contained the laundry area, extra food, and additional storage. Washer, dryer, cleaning supplies and chemicals are stored and inaccessible to residents. Emergency water is stored in the garage. The LPA did not observe any obstructions to emergency exit pathways. KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food, as well as emergency food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. At 11:15 A.M., hot water temperature measured 109.4 degrees Fahrenheit. RECORD REVIEW: Record review began at 11:45 A.M., records were reviewed for but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All 5 (five) resident records reviewed were missing needs and service appraisal, also, 2 (two) resident’s TB test results were not on their medical assessment. Licensee was not able to provide test result during the visit. 3 (three) staff files and administrator file were reviewed; all 4 (four) staff files reviewed were complete. Last Emergency Drill was conducted on 06/27/2024. Continued from LIC 809 Continued from LIC 809 MEDICATION REVIEW: Medications were observed locked in a cabinet across from the kitchen. Review began at 2:30 P.M. Medications for 5 (five) residents were observed. All 5 (five) residents' medications were observed to be maintained and administered in compliance with regulation. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). One (1) civil penalties was issued, totaling $500. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 13, 2024