Pepper Tree Assisted Living

Type of visit: Required - 1 Year

On 12/04/2025 at 12:00 pm, Licensing Program Analyst LPA) Jose Calderon conducted an unannounced annual inspection visit at the Pepper Tree Assisted Living Facility. LPA Calderon was allowed entry into the facility by Staff Joseph Matias. Facility is to operate a Residential Care Facility for 6 Elderly residents 60 years or older. Currently, there are four (4) residents residing in the facility, 60 and older. LPA Calderon explained to Staff Joseph Matias, the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Four (4) client service records, four (4) client medication records (MAR), two (2) staff records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 10/24/2025. The one-story residential home consists of five (5) client bedrooms, four (4) client bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored on the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the garage and kitchen area. LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of client’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 112 degrees Fahrenheit, bathroom #2 hot water temperature properly measured at 113 degrees Fahrenheit, Bathroom #3 hot water temperature properly measured at 113 degrees Fahrenheit, and bathroom #4 hot water temperature properly measured at 112 degrees Fahrenheit. Kitchen hot water temperature properly measured at 114 degrees Fahrenheit. Facility (1) Carbon Monoxide and (5) Smoke Detectors hard wired operated and connected were tested and are working properly. The facility one (1) Fire Extinguishers was checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. The facility has a working landline telephone. All toxins and knives are locked/secured and inaccessible to clients. Medications are centrally stored and in a locked storage cabinet. Facility 2 first aid kit is fully stocked with manuals checked and in order. Outside grounds were toured and there is no water feature observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to clients. Four (4) client files were reviewed and found to be complete. LPA Calderon reviewed four (4) resident medications (MAR) and they were all found to be administered according to doctor's orders. Two (2) staff files were checked and have the required documents. LPA Calderon noted the Administrator Marhlyn Sapugay Certification # 7033660740 expiration date of 10/03/2026 was valid at time of inspection. Commercial General Liability Policy #PCI6834654802 policy period from 02/10/2025 to 02/10/2026 underwritten by Primary Care Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. All the required documents are posted in the facility in a clearly visible area. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did observe deficiencies therefore citations were issued at this time. Annual Licensing Fee is CURRENT. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Staff Joseph Matias.the state’s words, verbatim · CDSS document, Dec 4, 2025

Type of visit: Required - 1 Year

On 12/05/2024 at 09:00 AM, Licensing Program Analyst LPA) Jose Calderon conducted an unannounced annual inspection visit at the Pepper Tree Assisted Living Facility. LPA Calderon was allowed entry into the facility by Staff Hilma Matias. Staff Hilma Matias asked infection control questions and took LPA Calderon temperature prior to entrance into the facility. Facility is to operate a Residential Care Facility for 6 Elderly residents 60 years or older. Currently, there are five (5) residents residing in the facility, 60 and older. LPA Calderon explained to Staff Hilma Matias, the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Five (5) client service records, five (5) client medication records (MAR), two (2) staff records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 10/01/2024. The one-story residential home consists of five (5) client bedrooms, four (4) client bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the garage and kitchen area. LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of client’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 109 degrees Fahrenheit, bathroom #2 hot water temperature properly measured at 110 degrees Fahrenheit, Bathroom #3 hot water temperature properly measured at 110 degrees Fahrenheit, and bathroom #4 hot water temperature properly measured at 112 degrees Fahrenheit. Kitchen hot water temperature properly measured at 115 degrees Fahrenheit. Facility (1) Carbon Monoxide and (5) Smoke Detectors hard wired operated and connected were tested and are working properly. The facility one (1) Fire Extinguishers was checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. The facility has a working landline telephone. All toxins and knifes are locked/secured and inaccessible to clients. Medications are centrally stored and in a locked storage cabinet. Facility 2 first aid kit is fully stocked with manuals was checked and in order. Outside grounds were toured and there is no water feature observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to clients. Five (5) client files were reviewed and found to be complete. LPA Calderon reviewed five (5) resident medications (MAR) and they were all found to be administered according to doctor's orders. Two (2) staff files were checked and have the required documents. LPA Calderon noted the Administrator Marhlyn Sapugay Certification # 6018525740 expiration date of 10/03/2024 was NOT valid at time of inspection. The facility does not handle client's money/cash resources and no surety bond is needed. Commercial General Liability Policy #PCI6834654801 policy period from 02/10/2024 to 02/10/2025 underwritten by Primary Care Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. Administrator Valencia to email LPA Calderon a full copy of the commercial insurance policy including all endorsements no later than 12/20/2024. All the required documents are posted in the facility in a clearly visible area. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and clients, sanitizing stations (Located in common areas and restrooms). LPA observed staff and clients were NOT wearing face coverings. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA Calderon advised the Staff Hilma Matias to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did observe deficiencies therefore citations were issued at this time. Annual Licensing Fee is CURRENT. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Staff Hilma Matias.the state’s words, verbatim · CDSS document, Dec 5, 2024

Type of visit: Annual/Random

On 01/13/2024 at around 9:30 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Caregiver / House Manager Emma Fernandez. LPA explained the purpose of the visit and was accompanied by staff inside and outside the facility during this inspection. This facility is licensed to serve 6 adults ages 55 and above. A total of 5 residents are currently residing in this facility. The facility is a one-story house located in a residential street. The home consists of 5 resident bedrooms, 4 bathrooms, 1 living room, 1 kitchen, 1 attached garage, and a backyard and front yard patio area with shaded seating. Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet. LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There is one fire extinguisher in the kitchen area and it was last serviced on 09/12/2023. There is a landline phone in the kitchen. There is no videoconferencing device dedicated for resident use. 5 out of 5 resident’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb. 5 staff records were reviewed, 5 out of 5 staff records had Criminal Record Clearances, Job Applications, Tuberculosis Test, and Facility Training's. 5 resident records were reviewed and, 5 out of 5 resident records had Admission Agreements, Medical Assessments, Consent Forms, Weight Record, Emergency Information, Appraisal & Needs Service Plan, Tuberculosis Test, Centrally Stored Medication Destruction Record, and Personal Rights. Deficiencies are being cited based on LPA observation and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding videoconferencing device dedicated for resident use. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator.the state’s words, verbatim · CDSS document, Jan 13, 2024

The state marks this report as 8 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff are not addressing pest infestation at the facility. Uncleared adult(s) are working at the facility.

On 12/22/2023 at around 12:55 pm, LPA Lourdes Montoya conducted an initial 10-day complaint visit at this facility to investigate the above allegations. LPA met with Caregiver Emma Fernandez. LPA explained the purpose of today's visit. Administrator Marhlyn Sapugay arrived shortly after and assisted LPA Montoya with the visit. The investigations consisted of the following: LPA toured the facility with Administrator Marhlyn Sapugay. LPA obtained and reviewed the staff roster & resident roster, timesheets, and other pertinent records. LPA conducted interviews with two staff (S1 and S2). LPA observed two residents (R1 and R2) present and both residents (R1 and R2) were sleeping. LPA was unable to obtain statements from R1 and R2. REPORT CONTINUED IN LIC 9099-C Unsubstantiated Investigations revealed the following: Allegation: Staff are not addressing pest infestation at the facility. SOC 341 indicates “The facility is cockroach infested”. It is alleged that staff are not addressing pest infestation at the facility. On 12/22/2023 at 1:00 pm, LPA Montoya toured the facility. LPA observed two insect traps in the kitchen on the floor. From 1:20 pm – 1:45 pm, LPA Montoya interviewed two staff (S1-S2). Based on interview with S1, it was revealed that the facility has pests and licensee hired Orkin to provide pest control services to the facility. S2 stated Orkin began pest control services a few months ago and continued to provide treatments to inside and outside areas of the facility every other two weeks. From 1:50 pm – 2:15 pm, LPA Montoya reviewed the Orkin service reports. Based on records review, the facility has a pest control service agreement with Orkin dated 8/12/2023. LPA observed Orkin serviced the facility on August 12, September 19, October 11, 16, 20, 30, November 6, 10, 30 and December 16 of 2023. Service reports show Orkin inspected for pest activity and treated in common areas as necessary, both interior and exterior grounds. Based on records review, interviews and observations, the facility has timely taken the necessary actions to combat the pest infestation and therefore there is not enough evidence to prove the above allegation. Allegation: Uncleared adult(s) are working at the facility. SOC 341 indicates “The facility has been hiring undocumented caregiver with no permission to work”. It is alleged that “Uncleared adult(s) are working at the facility”. On 12/22/2023 from 1:50 pm – 2:15 pm, LPA Montoya conducted interviews with S1 and S2. Both S1 and S2 stated there are two regular caregivers (S2-S3), three caregivers/relievers (S4-S6), and the administrator (S1) working at this facility and . REPORT CONTINUED IN LIC9099-C From 2:20 pm – 2:30 pm, LPA reviewed the staff roster (LIC 501), Personnel Summary and time sheets. Based on LPA’s records review, all staff (S1-S6) working at this facility have California background clearances. Based on records review, interviews and observations, there is not enough evidence to prove the above allegation. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; Therefore, the allegations, "Staff are not addressing pest infestation at the facility” and “Uncleared adult(s) are working at the facility” are found to be UNSUBSTANTIATED. No deficiencies were cited during this visit. An exit interview was conducted with Administrator Marhlyn Sapugay and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 22, 2023 · control 11-AS-20231220145901