Pepper Tree Assisted Living III

Type of visit: Required - 1 Year

On 12/04/2025 at 09:30 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Pepper Tree Assisted Living 3. LPA Calderon was allowed entry into the facility by Staff Ricarte Lapuz. The Facility is licensed to serve residents aged 60 and over, five non- ambulatory residents. Currently, there are two (2) residents residing in the facility. LPA Calderon explained to Staff Ricarte Lapuz 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: Two (2) client service records, two (2) client medication records (MAR), two (2) staff records, and inspected the inside facility and outside grounds. The facility’s last fire drill was conducted on 11/03/2025. The two-story residential home consists of three (3) client bedrooms, one (1) client bathroom for Pepper Tree 3, 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 or found on the premise grounds. The 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 patio/garage 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 105 degrees Fahrenheit. Kitchen hot water temperature properly measured at 105 degrees Fahrenheit. Facility seven (5) Carbon Monoxide and seven (5) Smoke Detectors, hard-wired and connected, were tested and are working properly. Facility two (2) Fire Extinguisher 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 one (1) first aid kits are fully stocked with manuals being checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to clients. Two (2) client files were reviewed and found to be complete. LPA Calderon reviewed two (2) resident medications (MAR) and they were all found to be administered according to doctor's orders. Two (2) staff files were checked, and they have the required documents. LPA Calderon noted the Administrator Stephanie Klein Certification # 7019163740 expiration date of 05/15/2027 was valid at time of inspection. Commercial General Liability Policy #SRRG2025308 policy period from 07/18/2025 to 07/18/2026 underwritten by Sunland 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 not observe deficiencies therefore no 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 Ricarte Lapuz.the state’s words, verbatim · CDSS document, Dec 4, 2025

Type of visit: Case Management - Annual Continuation

On January 16, 2025 Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced Case Management Continuation inspection to complete inspection that was started on 12/19/2024. LPA met with Ricarte Lapuz, Assistant Administrator and explained the purpose of this visit. The facility is licensed to operate for (5) ambulatory Residents. The facility is approved for (2) hospice residents. There are currently 3 residents in care. Structure: The facility is on the second floor of a two story house located in a residential neighborhood and consists of three (3) bedrooms, one (1) bathroom, living room, dining area, a kitchen, and a covered outdoor patio and a garage on the first floor. The facility is clean and sanitary. Indoor passageways are free of obstructions. All window screens are clean and in good repair. The facility temperature is between 68 degrees and 85 degrees. Files/Postings LPA reviewed three (3) staff files and found that ( 3) out of (3 ) contain the required documents, certification, and training. LPA reviewed (3) client files and found that ( 3 ) out of (3) contained the required documents. LPA observed all required posting including license, personal rights, “see something, say something,” activity schedule, infection control signs. During file review, LPA observed all licensing fees are current. No deficiencies were cited during inspection. LPA conducted final interview with House Manager, Ricarte Lapuz , and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 16, 2025

Type of visit: Required - 1 Year

On December 19, 2024, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced required annual visit using the CARE Inspection Tools. LPAs met with Ricarte Lapuz, Assistant Administrator and explained the purpose of this visit. The facility is licensed to operate for (5) ambulatory Residents. The facility is approved for (2) hospice residents. There are currently 3 residents in care. Structure: The facility is on the second floor of a two-story house located in a residential neighborhood and consists of three (3) bedrooms, one (1) bathroom, living room, dining area, a kitchen, and a covered outdoor patio and a garage on the first floor. The facility is clean and sanitary. Indoor passageways are free of obstructions. All window screens are clean and in good repair. The facility temperature is between 68 degrees and 85 degrees. Physical Plant LPA and Ricarte Lapuz toured the facility inside and outside. LPA observed There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. LPA observed that facility had required postings: ombudsman poster, see something say something poster, emergency numbers, clients rights, facility sketch. Page 1 of 3 Bedrooms LPA inspected all 3 bedrooms. All bedrooms were observed to have the required furniture including beds, dressers, night stands with lamps, chairs, and ample storage space for personal belongings. All bedrooms were observed to be clean, in good repair, and have ample lighting. Bathrooms LPA inspected the facility bathroom. In the resident’s bathroom the toilet, faucets, and shower were fully operational. All safety handrails were securely fastened. LPA observed the showers to be clean and free of mold or mildew. The shower had a nonskid material in bottom and shower chair. The water temperature measured 105.4-degrees Fahrenheit. The toilet and faucets are operational. The bathroom was observed to be clean, in good repair and within Title 22 regulations. Linens & Hygiene LPA observed all beds to have the required linens including mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed an ample supply of linens, towels, and blankets. Kitchen/Laundry Room LPA inspected the kitchen and observed all appliances to be in good working repair, including stove/oven, microwave, washer, dryer located in garage. LPA observed knives and additional sharps to be secured in locked drawers in the kitchen and are inaccessible to residents. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. Cleaning products and toxins were secured in garage that is inaccessible to clients. Page 2 of 3 Common Rooms In the living room, LPA observed sofa, 3 chairs, mounted TV. In the dining room, LPA observed a 6 seated dinning table Safety LPA observed and tested smoke/carbon monoxide detectors to be fully operable. LPA observed (1) fully charged fire extinguisher mounted on the wall, last serviced on 10/11/24. LPA inspected the First Aid kit and found it contained an ample supply of required items: Scissors, tweezers, gauze, disinfectant wipes, band aids and a manual. LPA observed all exits to be clear and easily accessible. There are no firearms or ammunition stored on the premises. Due to time constraints LPA to complete inspection on a subsequent visit. There were no deficiencies cited during today’s inspection. Exit interview conducted and copy of this report given to Ricarte Lapuz. Page 3 of 3the state’s words, verbatim · CDSS document, Dec 19, 2024

Allegation investigated: Licensee is operating beyond the scope of their license. Licensee is not ensuring that the facility is propertly secured. Resident's are left unsupervised while in care. Uncleared adult (s) working at the facility.

On 02/23/2024, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint visit to deliver findings regarding the above allegations. LPA Richard met met with administrator Marhlyn Sapugay. LPA Richard and Adminitrator Flores toured the physical plant. The investigation consisted of the following: On 12/22/2023, LPA Richard reviewed and requested, staff and resident's records. LPA requested three residents (R1-R3) residents, and Two (2) staff (S1-S2) files. LPA Richard requested facility documents. Physician report, Needs of service plan, staff and resident roster, employee schedule, first aid certificate, training log. Due to times constrained and resident tested positive for Covid-19 the above allegations need further investigation. On 02/23/2024, LPA Richard conducted a subsequent complaint to deliver findings regarding the above allegations. Report Continues, See LIC9099C. Unsubstantiated The investigation revealed the following: Regarding allegation: Licensee is operating beyond the scope of their license. It is alleged that the licensee is operating beyond the scope of their license. LPA Richard interviewed the administrator about the complaint allegation. The administrator stated that during the pre-licensing on 11/16/23, the application initially was for six ambulatory residents. However, due to insufficient space the capacity was reduced to five (5) residents. The administrator stated that she has never gone beyond three residents since the facility opened, the facility has been losing residents for the last past two months. Now the facility capacity has been reduced by two (2) residents. LPA reviewed the resident roster and interviewed R1-R2. They both state that they only remembered two or three of them living here. R1-R2 stated that now it only the two of us. Based on information gathered, records reviewed, and interviewed, LPA did not find enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore, the allegation is unsubstantiated. Regarding the allegation: Licensee is not ensuring that the facility is properly secured. It is alleged that Licensee is not ensuring that facility is properly secured. LPA Richard toured the facility with the administrator, LPA observed there is an auditory devices to notify staff when someone walks through the backdoor from the room. The administrator stated that the facility is not a locked and there are no alarms. However, the facility has an auditory device on exits through the backdoor. LPA asked the administrator to test the backdoor auditory device. There was a loud sound when the back door was opened. LPA interviewed staff (S1-S3) the staff stated that the residents don’t go outside without the staff accompanying them. The residents mostly stayed inside the living room area, watching TV and playing games. LPA interviewed residents R1-R2 both stated that it is cold to go outside right now they always asked the staff go outside with them if they want to go out. The residents R1-R2 stated that they feel secured, especially when going downstairs to play with the other residents. Based on observation, records reviewed, and interviewed, LPA did not find enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore, the allegation is unsubstantiated. Regarding the allegation: Resident are left unsupervised while in care. It is alleged that the resident's are left unsupervised while in care. LPA Richard observed open entry to the facility, there was a staff member present, and there was a staff member at the facility while the residents were eating breakfast. LPA interviewed the resident R1-R2 regarding the residents left unsupervised at the facility, and the residents stated that staff were always present at the facility. The residents said they used the pendant to call the staff if they needed help. The residents stated that going downstairs is a plus, and they are never alone. LPA interviewed staff S1-S3 regarding the allegation; the staff stated that the facility always has one staff present upstairs if a resident doesn’t want to come downstairs. Staff stated that no residents were ever left alone upstairs at any given time. Based on information gathered, records reviewed, and interviews conducted, LPA did not find enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore, the allegation is unsubstantiated. Regarding the allegation: Uncleared adult (s) working at the facility. It is alleged that uncleared adult (s) working at the facility, LPA Richard reviewed the personnel file and showed that all the staff S1-S3 and everyone associated with the facility have a background clearance on file. The administrator stated that they do not hire anyone unless their background is cleared. On 02/12/24, Personnel Report Summary (LIS) showed everyone associated with the facility was cleared. Based on information gathered, record reviewed, and interviews conducted, LPA did not find sufficient evidence to support the allegation. Although the allegation 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. There were no deficiencies cited. Exit interview conducted a copy of this report was provided to the administrator Marhlyn Sapugay.the state’s words, verbatim · CDSS document, Feb 23, 2024 · control 11-AS-20231220153341

Type of visit: Prelicensing

On 11/16/2023 at 10:30 AM, Licensing Program Analyst (LPA) Lourdes Montoya conducted an announced pre-licensing visit to this home. LPA was greeted by Applicant Stephanie Klein and Staff Marhlyn Sapugay and explained the purpose of today’s pre-licensing inspection visit. An application dated 8/25/2023 was submitted to CCLD for an initial application for a Residential Care Facility for Elderly License. The applicant requested a capacity of six (6) ambulatory individuals. However, due to insufficient space on one of the bedrooms (bedroom #1), applicant agreed to reduce the capacity to five (5) ambulatory individuals. A new fire clearance for five ambulatory individuals was obtained on today's visit. Structure: The facility is on the second floor of a two-story house located in a residential neighborhood and consists of three (3) bedrooms, one (1) bathroom, living room, dining area, a kitchen, and a covered outdoor patio and a garage on the first floor. The facility is clean and sanitary. Indoor passageways are free of obstructions. All window screens are clean and in good repair. The facility temperature is between 68 degrees and 85 degrees. Bedrooms (Residents): The facility has three (3) bedrooms for ambulatory clients. Client bedrooms are large enough to allow for easy passage and to accommodate furniture and assistive devices such as wheelchairs, walkers, or oxygen equipment. No client bedroom is a passageway to another room, bath, or toilet. Bedrooms (Staff): There is no staff bedroom. Bathrooms: The home has one (1) bathroom. The resident bathroom has a working toilet and washbasins. Evaluation Report Continued in LIC809-C Linens & Hygiene Supplies: Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in a cabinet in the bathroom and in the garage. Emergency Phone Numbers, Exit Plan & Menu: Emergency phone numbers. The exit plan and menu are posted and readily available for review throughout the home. There is one (1) fire extinguisher located in the dining area. A telephone line (424-263-4636) is available in the living room. Personal Protective Equipment supplies are stored in the garage. The applicant’s Infection Control Plan was approved. Food Service: All kitchen areas are clean and free of litter, rodents, vermin, and insects. The refrigerator and freezer are clean and of adequate size. The freezer is maintained at 0 degrees Fahrenheit and the refrigerator is below the required maximum of 40 degrees Fahrenheit. A two (2) day supply of perishable foods and a seven (7) day supply of non-perishable food were observed. All equipment, appliances, dishes, and utensils are clean and well maintained. Smoke Detectors: Smoke and carbon monoxide detectors throughout the interior space are operable. Water Temperature: The water temperature measures 107.8 degrees Fahrenheit in the resident bathroom. Medications, First-Aid Kit & Book: The client's medications will be stored in a locked cabinet in the living room. Clients & Staff Files: The applicant will not be handling the cash resources of the residents. Records of staff and residents will be stored in a locked cabinet in the living room. Reading Material, Games, Equipment & Materials: LPA observed board games, books, magazines, and other recreational materials for the client's use all stored in the living room. Pool/Jacuzzi & Pets: There are no pets, jacuzzi, or pool in the fenced area. Fire clearance: A revised Fire Clearance was obtained on 11/16/2023 with approval for a capacity of five (5) ambulatory individuals. Component III: The applicant, Stephanie Klein, completed the Component III during the Pre-Licensing visit on 11/16/2023. Information provided about how to operate the facility within substantial compliance. When the applicant was asked if she understood Title 22, she responded in the affirmative. An exit interview was conducted, and a copy of this report has been furnished to Applicant Stephanie Klein. LPA Montoya will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application. END OF REPORTthe state’s words, verbatim · CDSS document, Nov 16, 2023

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: INITIAL Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Name - Stephanie Klein CEO/Administrator Interview Method: Telephone interview On October 31, 2023, Applicant/Administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of the following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-Licensing Readinessthe state’s words, verbatim · CDSS document, Oct 31, 2023