Newcomb Guest Manor

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Iwona Kaya, administrator for the facility, and explained the purpose of the facility. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control plan is on file. Physical Plant/Environment Safety: · The facility is a single-story home located in a residential neighborhood. The facility consists of four (4) resident bedrooms, an office, a caregiver room, a kitchen, dining room, a living room, and an attached garage that contains the washer and dryer for the facility. The facility contains three (3) bathrooms including checking their water temperature, which all fell within the required range of 105 – 120 degrees Fahrenheit. The carbon monoxide detector is operational in the home. A fully charged fire extinguisher is kept on the premises. The facility was observed to be in good repair. Operational Requirements: · Fire clearance was approved by LA County Fire Department for a capacity of six (6) non-ambulatory residents, and a hospice waiver approved for six (6) residents. · Care and supervision to meet the clients’ needs was observed. Staffing: · Five (5) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: · Five (5) staff files were reviewed for criminal background clearance and training. · All five (5) staff records have a health screening with a Tuberculosis clearance, First Aid/CPR trainings that are active, and required annual trainings. · Administrator’s certificate expires on 8/15/2027. Resident Rights/Information: · Physician orders were reviewed for five (5) resident files. · Medications were also reviewed for five (5) residents. Resident Records/Incident Reports: · Five (5) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. were observed. Exit interview held and a copy of the report along with appeal rights were provided. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have are assisted with medication management by staff. Disaster Preparedness: · Emergency and Disaster Plan (LIC610E) was posted in the facility and LPA obtained a copy. · The last emergency and disaster drill was conducted on 5/10/2026. Planned Activities: · Sufficient Space is provided to accommodate both indoor and outdoor activities. · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies following the visit. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 22, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with TJ Novallo, caregiver for the facility, and explained the purpose of the visit. Administrator Iwona Kaya arrived shortly thereafter. There are six (6) non-ambulatory residents residing within the home. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control plan is on file. Physical Plant/Environment Safety: · The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) non-ambulatory residents over the age of sixty (60), all of whom may receive hospice services. The facility consists of a kitchen, a dining room, a living room, a caregiver room, an office, an attached garage that has the washer and dryer for the facility, four (4) resident bedroom, an office, and three (3) restrooms which had hot water temperature readings of 105.2 Degrees Fahrenheit, 105.4 Degrees Fahrenheit, and 108.1 Degrees Fahrenheit. Facility was observed to be in good repair. · The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has multiple fully charged fire extinguishers kept in the facility. Operational Requirements: · The Program Design was reviewed. · Fire clearance was approved by LA County Fire Department for a capacity of six (6) non-ambulatory residents over the age of sixty (60), all of whom may receive hospice services. · Care and supervision to meet the clients’ needs was observed. Staffing: · Six (6) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: · Five (5) staff files were reviewed for criminal background clearance and training. · All Five (5) staff records reviewed have a health screening with a Tuberculosis clearance, and four (4) staff have First Aid/CPR trainings that are active. · One (1) staff member has an expired CPR certificate that needs to be renewed. · The administrator’s certificate expires on 8/25/2025. Resident Rights/Information: · Physician orders were reviewed for six (6) resident files. · Medications were also reviewed for six (6) residents. Resident Records/Incident Reports: · Five (5) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. · Two (2) residents did not have reappraisal conducted within the past year. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have an Appraisal/Needs and Services Plan on file. · Staff training was on file. Disaster Preparedness: · Emergency and Disaster Plan (LIC610E) was posted in the facility. · The last emergency and disaster drill was conducted on 4/29/2025. Planned Activities: · Sufficient Space is provided to accommodate both indoor and outdoor activities. · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit is documented on the LIC809D page. Exit interview held and a copy of the report along with appeal rights will be provided by email.the state’s words, verbatim · CDSS document, Jul 1, 2025

Allegation investigated: Staff do not provide enough food for residents in care

***This report supersedes report dated on 7/16/2024. The reason the report is being superseded is because the deficiency type needs to be updated to a "Type A" violation rather than a "Type B" violation. Additionally, the Plan of Correction (POC) due date needs to be updated as well. All other findings will remain the same.*** Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced initial complaint visit to investigate the allegations listed above. LPA met with TJ Navallo, caregiver for the facility, and was granted entrance into the facility. The investigation consisted of the following: LPA obtained the facility staff and resident rosters, examined the food supply for the facility, obtained the FACE Sheets for Residents #1 - 6 (R1 - R6), obtained the admission agreement for R1, and interviewed R1 - R6, Staff #1 - 3 (S1 - S3), and Witness #1 (W1) as well. Substantiated The investigation revealed the following: In regards to the allegation that "Facility does not have a sufficient food supply," it was alleged that the facility's refrigerator was bare when it was checked. During interviews with the residents, one (1) out of six (6) residents interviewed corroborated the allegation that at times the facility does not have enough food. One of the residents interviewed stated that the food supply is "up and down" at times. Another resident interviewed stated that they get enough food and haven't been aware of the facility being out of food in the past. During interviews with the staff, zero (0) out of three (3) interviewed stated that they do not have a sufficient food supply. One of the staff interviewed stated that they make sure that every resident gets food when they request for it. Another staff interviewed stated that residents get three (3) meals per day along with snacks, and that grocery shopping is done every week. Upon checking the facility's perishable food supply, LPA determined the required two (2) day supply was not met for the six (6) residents living in the facility. Based on LPA interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 is being cited on the attached LIC9099D. Exit interview held and a copy of the report and appeal rights was provided to the administrator Iwona Kaya.the state’s words, verbatim · CDSS document, Sep 10, 2024 · control 28-AS-20240715094833

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(26) · Plan of correction due date: Sep 11, 2024

(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 met as evidenced by: Based on interview and observation, LPA determined that there was not a sufficent 2-day supply of perishable foods within the facility for residents, which poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Sep 10, 2024

Plan of correction: Administrator is to ensure that the food supply requirement is maintained on the premises at all times. Administrator is to increase the facility's perishable food supply and submit proof to LPA that it has been restocked by the POC due date.

Allegation investigated: Facility does not have a sufficient food supply Staff would not allow resident to have a visitor Facility staff restricting resident's telephone access

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced initial complaint visit to investigate the allegations listed above. LPA met with TJ Navallo, caregiver for the facility, and was granted entrance into the facility. The investigation consisted of the following: LPA obtained the facility staff and resident rosters, examined the food supply for the facility, obtained the FACE Sheets for Residents #1 - 6 (R1 - R6), obtained the admission agreement for R1, and interviewed R1 - R6, Staff #1 - 3 (S1 - S3), and Witness #1 (W1) as well. The investigation revealed the following: In regards to the allegation that "Facility does not have a sufficient food supply," it was alleged that the facility's refridgerator was bare when it was checked. Substantiated During interviews with the residents, one (1) out of six (6) residents interviewed corroborated the allegation that at times the facility does not have enough food. One of the residents interviewed stated that the food supply is "up and down" at times. Another resident interviewed stated that they get enough food and haven't been aware of the facility being out of food in the past. During interviews with the staff, zero (0) out of three (3) interviewed stated that they do not have a sufficient food supply. One of the staff interviewed stated that they make sure that every resident gets food when they request for it. Another staff interviewed stated that residents get three (3) meals per day along with snacks, and that grocery shopping is done every week. Upon checking the facility's perishable food supply, LPA determined the required 2-day supply was not met for the six (6) residents living in the facility. In regards to the allegation that "Staff would not allow resident to have a visitor," it is alleged that family members of R1 have not been allowed to visit R1 since 7/3/2024 due to R1's Power of Attorney (POA) request that they do not visit R1 due to safety concerns. During interviews with the Residents, one (1) out of six (6) residents interviewed did not corroborate the allegation. R1 explained during the interview that they would actually like their family that was prevented from visiting them on 7/15/2024 to visit them. None of the other residents interviewed stated that they are prevented from receiving visitors at the home. During interviews with the staff, none of them corroborated that they are improperly restricting the visitation rights of residents. One staff member interviewed stated that R1 has been financially abused and neglected by the family members in the past, and that is why R1's POA has requested that the other family members of R1 do not visit them at the facility. During record review of R1's POA document LPA did not observe anything in writing indicating that POA can restrict R1's visitation rights. LPA was not provided any legal documentation indicating that R1's visitation rights can be restricted by the facility staff. In regards to the allegation "Facility staff restricting resident's telephone access," it is alleged that the facility staff are not picking up calls from R1's family who have been attempting to contact R1. During interviews with the residents, one (1) out of six (6) residents interviewed indicated that they do not have access to speak with their family through the facility's phone. During an interview with R1 they stated that they have not been allowed to speak with their family members by phone, and they are not aware of the reason why they haven't been allowed to speak with their family. Another resident interviewed stated that sometimes there will be an individual using the phone so it is not immediately available, however it is typically always available. During interviews with the staff, two (2) out of three (3) corroborated that phone calls were restricted for R1's family. One staff interviewed stated that have been advised not to answer the phone whenever the family of R1 calls, and that R1's family calls from various phone numbers. Another staff interviewed was told that R1's POA has a preference that the facility staff do not accept calls from R1's other family members due to the potential for abuse, and therefore they have not been taking R1's family's calls, nor have they been notifying R1 that they are received calls from R1's family. Based on LPA interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC9099Ds. Exit interview held and a copy of the report and appeal rights was provided to the administrator Iwona Kaya. During interviews with the residents, zero (0) out of six (6) interviewed stated that staff have left them in the bathroom unassisted. During an interview with R1, they stated that they receive assistance with their toileting needs from the staff, and they have never left them in the bathroom when they required assistance. Another resident interviewed stated that they get assistance with their incontinence care from the staff at the facility. Other residents interviewed stated they do not require assistance with their toileting needs. During interviews with staff, zero (0) out of three (3) interviewed did not corroborate the allegation. One staff interviewed stated that they assist R1 with wiping personally by using specialized wipes that they keep in the resident rooms, and when R1 claims they are done toileting they call for this staff member, and the staff always assists in cleaning the resident afterwards. LPA observed the supply of wipes that were kept in the resident's room. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 16, 2024 · control 28-AS-20240715094833

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(26) · Plan of correction due date: Jul 30, 2024

(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 met as evidenced by: Based on interview and observation, LPA determined that there was not a sufficent 2-day supply of perishable foods within the facility for residents, which poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: Administrator is to ensure that the food supply requirement is met at the facility at all times. Administrator is to increase the facility's perishable food supply and submit proof to LPA that it has been restocked by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Jul 30, 2024

(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 (...) provided that the rights of other residents are not infringed upon. This regulation is not met as evidenced by: Based on interviews conducted, LPA determined that R1 has been denied visitation from his family members during his stay at the facility, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: Administrator is to ensure that all residents are allowed visitors at all times if the resident agrees they wish to see the visitors. Administrator is to submit a written plan on how the facility will mee the requirement going forward by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Jul 30, 2024

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have (...) telephone conversations (...) and meetings of resident and family groups. This regulation is not met as evidenced by: Based on interviews, LPA determined that the resident had not been allowed to speak with their family members on the phone when they called the facility, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: Administrator is to ensure that all residents are allowed to speak with their family members when they call the facility number. Administrator is to submit to LPA the facility's plan on how they will meet the regulation by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Gerardo Navallo, caregiver for the home, and was granted entrance to the facility. Administrator Iwona Kaya arrived shortly thereafter. There are five (5) residents currently living in the facility, of which one (1) of them is on hospice. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control plan was present within the facility. Physical Plant/Environment Safety: · The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) non-ambulatory residents, along with a hospice waiver approved for six (6) residents. The facility consists of a kitchen, a living room, a dining room, four (4) resident rooms, a staff room, an office, three (3) resident bathrooms of all three (3) had a hot temperature reading between 97.7 Degrees F, 97.1 Degrees F, all of which fell below the required range of 105 – 120 degrees Fahrenheit, a backyard patio area, and an attached garage that contains the facility’s washer and dryer machines and emergency food supplies. The facility’s chemicals, cleaning supplies, and knives are kept locked and inaccessible to residents. The facility was observed to be in good repair. ·The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has two (2) fully charged fire extinguisher located in the kitchen of the facility as well as in the garage. · Water temperature readings fell below the required range of 105 - 120 degrees Fahrenheit. Operational Requirements: · The Program Design was reviewed. · Fire clearance was approved by LA County Fire Department for a capacity of six (6) non-ambulatory residents, along with an approved hospice waiver for six (6) residents · Care and supervision to meet the clients’ needs was observed. Staffing: · Six (6) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: · Five (5) staff files were reviewed for criminal background clearance and training. · Four (4) out of five (5) staff records reviewed have health/TB screenings, however one (1) did not have a completed health screening on file. All had current 1st Aid/CPR training. · The administrator’s certificate expires on 8/15/2025. Resident Rights/Information: · Physician orders were reviewed for five (5) resident files. · Medications were also reviewed for five (5) residents. Resident Records/Incident Reports: · Five (5) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have an Appraisal/Needs and Services Plan on file. · Staff training was on file. Disaster Preparedness: · Emergency and Disaster Plan was publicly posted and found within the facility. · The last emergency and disaster drill was conducted on 6/11/2024. Planned Activities: · Sufficient Space is provided to accommodate both indoor and outdoor activities. · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs: · A hospice care plan was in place for the one (1) resident who is on hospice. · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit is documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 14, 2024

Allegation investigated: Administrator did not provide a refund to resident's responsible party.

Licensing Program Analyst (LPA) Tao conducted an unannounced 10-day complaint visit to this facility and met Iwona Kaya, administrator. The purpose of today’s visit and the allegation were discussed. The investigation consisted of residents/ staff interviews, facility tours, and review of facility records. LPA obtained resident/staff roster and residents’ facility files. The investigation revealed the following: In regards of Administrator did not provide a refund to resident's responsible party, it was alleged that administrator failed to refund the remaining balance from the resident’s account to the responsible party after moved out. LPA attempted but failed to interview resident#1 (R1). Per resident interviews, from resident#2 to resident #4, all three (3) residents could not corroborate the allegation. Resident interviews revealed that residents had never requested a refund since residing at the facility. (-continued in LIC 9099C-) Unsubstantiated Per staff interview, from staff#1 to staff#3, all three (3) staff interviewed denied the allegation. Staff interviews revealed that administrator would handle the refund. Per administrator interview, the 2nd refund check was mailed out to the responsible party two days ago. Per record review, the balance was fully refunded. Therefore, administrator had refunded the resident's remaining balance to the responsible party. Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with administrator and the finding was discussed. A copy this report was provided at time of the visit.the state’s words, verbatim · CDSS document, May 24, 2024 · control 28-AS-20240521111539

Allegation investigated: Facility has failed to provide resident's medical records

Licensing Program Analyst (LPA) Jose Villalobos made an unannounced initial complaint visit in response to the above mentioned allegation. LPA Villalobos met with Administrator Iwona Kaya and the purpose of the visit was discussed. Iniital visit conducted on 1/5/23 and consisted of the following: LPA interviewed Administrator telephonically (S1) and toured the physical plant. LPA requested the following documents from Resident #1's (R1s) file: Facehseet, Physicians Report, Medication Records Log for the last month, Needs and Services Plan, Appraisal Sheet. As of todays visit, LPA interviewed Residents #2-#5 (R2-R5), Staff #2-#3 (S2-S3) and R1's responsible party. R1 is no longer in the facility and was unavailable for interview. The investigation revealed the following: Continued on LIC 9099-C Unsubstantiated In regards to the allegation "Facility has failed to provide resident's medical records" it was alleged that R1's medical records were requested by an authorized representative and the facility did not provide them. (3) of (3) Staff interviewed denied the allegation. (4) of (4) Residents interviewed could not corroborate the allegation. Interviews state that R1's responsible party had hired a law firm to collect medical records for R1. The medical records for R1 were requested on 12/21/22 by the firm. Once the facility verified the request, a copy of R1's file was provided via verified mail on 12/24/22. Interviews with S1 and R1's responsible party state that the medical records were meant to have been requested from a different facility where R1 had resided in the past and not from this facility. The facility would not have the medical records, that were being requested by the firm, that were from a time prior to R1 being admitted into the facility. R1's responsible party confirmed these details and did not have issue with the facility. Based on interviews, observations, and file review there was not enough supportive evidence to concur with the reported allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit Interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 2, 2023 · control 28-AS-20221227120626