New Hope Residential Elder Care II

Allegation investigated: Staff did not ensure there was adequate supply of food available for residents

On July 23, 2026, Licensing Program Analyst (LPA), Ivashia Wright, arrived unannounced at the facility to initiate a complaint investigation. LPA met with the Caregiver, Viva Gregorio. The LPA introduced themselves and explained the purpose for the visit. Administrator Annie Jane Mikenas arrived shortly after. LPA interviewed staff, Administrator, Witness and requested documentation. LPA also inspected the existing food supply. Regarding the allegation that Staff did not ensure there was adequate supply of food available for residents, it was reported that there is a concern for the amount of food available and the food may be insufficient to meet nutritional needs for all six residents. Continued on LIC9099-C Substantiated Interview with Annie, the Administrator, stated she has been shopping multiple times for the facility. Annie reported the facility goes shopping on Saturdays, but staff has been requesting more food. Annie stated staff doesn’t want to order too much food because residents hardly eat and do not want food to go bad. Information obtained from interviews with staff stated grocery shopping days were Thursdays and Sundays. Information obtained from interview with R1’s responsible party corroborated that there was a food shortage at the facility. R1’s responsible party stated she believes that there is now a variety of perishable food available. Although the LPA observed that the facility contained the 2-day perishable food requirement, the facility did not have the 7-day non perishable food available to meet the needs of the residents. Based on witness interviews, staff interviews, facility records, and LPA observations, the allegation staff did not ensure there was adequate supply of food available for residents is deemed substantiated. A substantiated finding means that the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated. A copy of this report, LIC 9099D, LIC 421FC, and appeal rights are being provided to Administrator Annie.the state’s words, verbatim · CDSS document, Jul 23, 2026 · control 18-AS-20260716111403

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(26) · Plan of correction due date: Jul 24, 2026

87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not as evidenced by: Based on observation, Licensee did not ensure the food supply for the number of residents, the facility has failed to meet the required supplies of maintaining on the premises nonperishable foods for a minimum of one week.the state’s words, verbatim · CDSS document, Jul 23, 2026

Plan of correction: Administrator to certify that the facility will maintain nonperishable foods for a minimum of one week. Proof of correction must be submitted to LPA Wright by 5pm on 7/24/2026.

Allegation investigated: Staff did not ensure there was adequate food for residents

On June 29, 2026, Licensing Program Analyst (LPA), Ivashia Wright, arrived unannounced at the facility to initiate a complaint investigation. LPA met with the Caregiver, Viva Gregorio. The LPA introduced themselve and explained the purpose for the visit. Administrator Annie Jane Mikenas arrived shortly after. LPA interviewed staff, Administrator and requested documentation. LPA also inspected the existing food supply. Regarding the allegation that Staff did not ensure there was adequate food for residents. LPA did not observe sufficient food to meet the 2 day perishable, 7 day non-perishable mandated by regulations. Interview with Administrator Annie informed LPA that she was out of the country. Annie stated staff were to call her son for grocery needs every Friday. Annie stated there is no menu provided to residents due to residents having different food options and needs. Continued on LIC9099-C Substantiated Information obtained from interviews with staff stated grocery shopping days were Saturday or Sundays. Interview with additional Staff stated they notified the son of grocery needs but too many things were needed and son couldn't supply all grocery needs. Staff did corroborated that the Administrator was out of country and that the son of the Administrator was responsible for providing grocers for the facility. Based on staff interviews, facility records, and LPA observations the allegation that staff did not ensure there was adequate food for residents is deemed substantiated. A substantiated finding means that the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated. A copy of this report, LIC 9099D, and appeal rights are being provided to Administrator Annie.the state’s words, verbatim · CDSS document, Jun 29, 2026 · control 18-AS-20260625162431

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87555(b)(26) · Plan of correction due date: Jun 30, 2026

87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not as evidenced by: Based on observation, Licensee did not ensure the food supply for the number of residents, the facility has failed to meet the required supplies of maintaining on the premises nonperishable foods for a minimum of one week and perishable foods for a minimum of two days.the state’s words, verbatim · CDSS document, Jun 29, 2026

Plan of correction: Administrator to certify that the facility will maintain nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. Proof of correction must be submitted to LPA Wright by 5pm on 6/29/2026.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ivashia Wright conducted an unannounced visit for a required annual inspection. The LPA was greeted by the Caregiver Vina Gregorio, notified her of the purpose for the visit and was allowed to enter the facility to conduct the inspection. At the time of the visit, there were two (2) staff members and five (5) residents present. Administrator Annie Mikenas arrived shortly after. Facility Overview: The facility is a single story building with four (4) residents bedrooms, one (1) staff bedroom, two (2) bathrooms, a dinning room, a family room, a kitchen area and a shed. There is no gated pool and there are no firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in the kitchen area and inaccessible to residents. The smoke detector and carbon monoxide detector were in good working condition. LPA observed fire extinguishers to be in compliance with the department requirements and with an expiration date of 2/25/2027. The water temperature was tested within regulations measuring at 110.2 F Continued 809-C.. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds both a current administrator’s certificate and cpr certificate. Record Review and Resident/Staff Files: LPA reviewed files for Three (3) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Three (3) resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for four residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire/earthquake drill conducted on 1/29/2026 and 1/30/2026, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided to Administrator Annie Mikenas..the state’s words, verbatim · CDSS document, Mar 4, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit for a required annual inspection. The LPA was greeted by the Caregiver Vina Gregorio, notified her of the purpose for the visit and was allowed to enter the facility to conduct the inspection. Facility Overview: The facility is a single story building with four(4) residents bedrooms, one staff bedroom, two(2) bathrooms, a dinning room, a family room, an office and a kitchen area. There is no gated pool and there are no firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in the kitchen area and inaccessible to residents. The smoke detector and carbon monoxide detector were in good working condition. LPA observed fire extinguishers to be in compliance with the department requirements and with an expiration date of January 24, 2026. The water temperature was tested within regulations measuring at 109.5 F Care & Supervision/Administration: Adequate staff were present to supervise residents during the visit. The administrator holds a current administrator’s certificate with expiration date of July 1, 2025 and a CPR certification with the expiration date of February 17, 2025 Continued 809-C...... Record Review and Resident/Staff Files: LPA reviewed files for two(2) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Three (3) residents' files were reviewed and contained all required documentation. LPA observed first kit to be locked and inaccessible to the residents in care. The residents files were kept in a locked cabinet in the office area and staff files were kept in a locked cabinet in the hallway and inaccessible to unauthorized individuals Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a cabinet and located in the kitchen area. LPA reviewed medications for two(2) residents, confirming that all medications were listed and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last emergency drill conducted on 02-5-2025, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed, and a copy was provided to Caregiver Vina Gregorio.the state’s words, verbatim · CDSS document, Mar 4, 2025

Allegation investigated: Resident sustained multiple scratches while in care. Resident not administered medication as prescribed. Medication not locked in a cabinet.

Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA met with Administrator, Jane Mikenas where LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of observation, interviews with staff members and residents, and records review. On 08/11/2021, Community Care Licensing received a complaint alleging Resident sustained multiple scratches while in care, Resident not administered medication as prescribed, and medication not locked in a cabinet. In regards to the allegation of the medication not locked, LPA interviewed Administrator, Jane Mikenas and she denied the allegation. Administrator stated that facility always locks the medications in the hallway door. LPA interviewed the staff members, who stated that the medications are always locked in the hallway closet. LPA made observation during her subsequent visit that confirmed medications are stored and locked in a centrally stored location in the hallway. The initial visit made by a previous LPA was not able to confirm or deny this allegation during the initiation of the complaint in 2021. Unsubstantiated In regards to the allegation that Resident sustained multiple scratches while in care. LPA was not able to interview Resident 1 (R1). R1 passed away on 08/15/2021. LPA interviewed Administrator who stated that there were no incidents that occurred where any facility staff member scratched the resident. LPA interviewed staff members who worked at the facility in 2021, who stated that they handled R1 with care and denied scratching R1. LPA interviewed residents who have been at the facility since 2021. Information obtained from residents indicated there was no issues with staff or care and supervision during the entirety of their residency at the facilities. LPA was unable to contact a representative from Arbor Hospice to obtain additional information. LPA reviewed the notes from hospice agency, which did not indicate any abnormal scratches. In regards to the allegation that residents are not administering medication as prescribed, LPA interviewed Administrator stated that staff review doctor’s orders and the medication is given to the residents on time, every day. Information obtained from interviews with staff members who worked at the facility in 2021 indicated that staff administer resident’s medications following doctor’s orders. Residents currently placed at the facility indicated no issues with receiving their medications as prescribed. LPA was unable to contact a representative from Arbor Hospice to obtain additional information. During the LPA’s record review, Medications Administrator Records (MARS) appeared to have been provided and filled out correctly. LPA also reviewed R1’s Centrally Stored Medication log. No additional documents were able to be reviewed due to the time frame since R1’s passing. Based on LPA’s observation, interviews conducted, and record review, the allegations that R1 sustained multiple scratches while in care, R1 not administered medication as prescribed, and medication not locked in a cabinet is unsubstantiated due to the inability to interview pertinent parties and review pertinent documentation. A finding of unsubstantiated means the allegations may have happened or is valid, but there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was discussed with and provided to the Administrator, Jane Mikenas.the state’s words, verbatim · CDSS document, Jul 29, 2024 · control 18-AS-20210811145213

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Licensee, Jane Mikenas, who was informed of the purpose of the visit. At time of visit there were (6) clients and (3) staff present. The facility is a one story home with licensed capacity on the first floor with (5) bedrooms and (2) bathrooms. The facility does not have a pool or fire arms. The facility is a residential care facility for the elderly serving elderly ages 60 and above. LPA observed the following: Infection Control: LPA observed hand hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a infection control plan on file. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The carbon monoxide detector were operational. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required food items. Record Review and Resident/Staff Files: LPA reviewed staff files and training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork. Health Related Services/ Incidental Medical Services: All client medication was locked in a hallway closet. LPA reviewed client medications and found that MARS and medication had discrepancies. LPA observe medication #1 (M1) was not punched but was documented on MARS as given. Medication #2 (M2), and Medication #3 (M3) and Medication #4 (M4) were documented as given, but the medication was still observed in the bubble pack on this date. Medication #5 (M5) indicated to have given for (7) days, had been ordered by the physician to be given for (5) days. Based on staff interviews, medication errors occur and staff are trained every (3) months. The deficiency was cited for medication administration and plan of correction was created. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted on 2/2/2024. An exit interview was conducted where a copy of this report, LIC809-D, LIC811, appeal rights and LIC9098 were reviewed and provided to, Licensee, Jane Mikenas.the state’s words, verbatim · CDSS document, Mar 15, 2024