Pepperwood Villa

Type of visit: Required - 1 Year

On 8/4/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit. LPA met with the Administrator, Elsa Roman and explained the purpose of today’s visit. The purpose of today’s visit was to conduct the required annual inspection, using the new Care Tool. The facility is licensed approved for age range 60 and over; Approved for six (6) non-ambulatory only residents. Hospice/waiver granted for hospice care for (2). The census is currently 5. Pepperwood Villa is a one-story structure located in a residential neighborhood. The facility consists of (5) resident bedrooms, two (2) bathrooms, living room, kitchen, dining area, shaded patio and the laundry is located in the kitchen. Four (4) bedrooms are occupied and one (1) bedroom is vacant. Facility maintains all required posting throughout the facility. LPA Shirley reviewed five (5) resident files, four (4) staff files, and five (5) resident medications. All resident and staff files were complete. The facility’s Emergency Disaster Plan was current. The facility does not handle any of the residents’ money. The annual fees are current. LPA Shirley and Elsa walked throughout the facility and all common areas such as the living room, dining room, and outdoor patio were all observed. The medications are stored in a cabinet in the living room, and sharps are stored in a kitchen cabinet, locked and inaccessible to clients in care. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water delivered at 115 F. LPA observed that there is ample seating and space for all clients. All walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. There are (2) charged fire extinguishers last serviced 4/25/26. Exterior areas are clean and clear of obstructions and hazards and there are no bodies of water present. The first aid kit was fully stocked and there was a first aid manual available. Elsa conducts the fire drill quarterly. Last fire drill conducted on 6/3/26. No deficiencies were cited during this inspection visit. An exit interview was conducted, and a copy of this report was provided to the Administrator, Elsa Roman.the state’s words, verbatim · CDSS document, Aug 4, 2026

Type of visit: Required - 1 Year

On 07/28/2025 at 11:15 am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced visit to the above facility. The purpose of today's visit was to conduct the one-year inspection. LPA met with Elsa Roman, Administrator and the purpose of the visit was discussed. The The facility is licensed to serve 6 non-ambulatory only residents and a waiver granted for an approved hospice care for five (5) residents. Five (5) of the residents are diagnosed with dementia, zero (0) residents receive home health, and one (1) of the residents are receiving hospice care services. The facility does not handle any of the residents’ money. The facility has a current administrator certificate (#7012218740) for Elsa Roman valid from 06/24/2024 - 06/23/2026. The facility fees are current. The facility has liability insurance with James River Casualty Company (NAIC# 13685) with each occurrence at $1,000,000 and general aggregate at $3,000,000 (policy #00150009-1) effective date 11/17/2024 - 11/17/2025. The facility fees are current. The home is a single home consisting of : (5) resident bedrooms, (2) full bathrooms, living room, a kitchen, a washer and dryer area, a dining area, a living room, a backyard with two (2) shed with additional storage and an outdoor shaded patio are in the backyard. Report continues on LIC 809-C Between the hours 11:29 am - 11:52 am, LPA toured the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. The water temperature measured at 112.5°F (in the kitchen), 112.5 °F (in bathroom #1) and 110.7°F (bathroom #2). Resident bath towels, toiletries, and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards doorways were free of obstructions. Between the hours of 11:52 am - 2:30 pm, LPA conducted a records review of (5) residents records, (5) staff records and (5) Client Medication Administration Records and the facility disaster plan. All client & staff records were complete. The facility disaster plan was current (last conducted on 07.08.2025) and in compliance with Title 22 at the time of visit. LPA did not observed any discrepancies at the time of visit. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous Items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. During today’s visit LPA did not observe any deficiencies. An exit interview was conducted with Elsa Roman (Administrator) and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 28, 2025

Type of visit: Prelicensing

On 07/08/2024 Licensing Program Analyst (LPA) Mario Leon conducted an announced visit to this home. LPA was met by Jose Umana, Administrator and LPA explained the purpose of today’s prelicensing inspection visit. An application was submitted to CCLD on 04/15/2024 in the initial license application for a Residential Facility for the Elderly, ages 60 years and above. The applicant requested a capacity of six (6) individuals, of which six may be (6) non-ambulatory and zero (0) bedridden residents. Structure: The home is a one-story, residential unit, without any garage and is located in a residential neighborhood. The home consists of five (5) bedrooms, two (2) bathrooms, one (1) Detached Accessory Dwelling Unit (ADU) for staff with one (1) staff toilet. The home includes a living, dining, kitchen area which includes a laundry area. The living room did not include a fireplace. The living area included recliner seating. The kitchen has a refrigerator and stove. The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions. Bedrooms Residents: The facility has five (5) bedrooms for residents. This includes all five (5) bedrooms for non-ambulatory residents. All rooms include a twin-size bed, one (1) chair, one (1) night stand, and one (1) table lamp. All bedrooms are equipped with a ceiling light. Four (4) rooms include a dresser and closet, one (1) shared room is fitted with a stand-alone closet, which complies with the requirement of 8 cubic feet of personal storage space. The rooms also include wall night lights. REPORT CONTINUES, SEE LIC809C. Bedrooms Staff: Detached ADU is designated for live-in staff, with one (1) toilet included within. Bathrooms: The home has two (2) bathrooms. All bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats. Linens & Hygiene Supplies: Beds have the required linen supplies which include, pillowcases, waterproof mattress pads, fitted sheets, flat sheets and blankets. An adequate supply of linen is stored in the northernmost hall closet . 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 are two (2) fire extinguishers located in the entryway and kitchen, both mounted on the wall, and are fully charged as of 05/07/2024 and are accessible to staff and residents. A telephone line is available in the facility at 562.354.6354. Emergency supplies and Personal Protective Equipment supplies are stored in the central closet. The applicant has an approved Infection Control Plan on file. Food Service: Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Cutlery has been supplied adequately. Knives and other sharp kitchen utensils are stored in a locked kitchen cabinet. Food supply is adequately stored in kitchen cabinets and consists of 7-day supply of non-perishable canned goods. The refrigerator is adequately stocked for, at least, 2-days of perishable foods. Smoke Detectors: Seven (7) smoke detectors and two (2) carbon monoxide detectors were observed throughout the interior space. All units were tested and are in working order. One (1) Carbon monoxide is located in the dining room and one (1) is located in northern hallway. Toxins: All toxins and detergents are locked and stored under the kitchen sink cabinet. Appliances: Stove burners, microwave, washer, and dryer are in working order. There is one (1) refrigerator in the home. The refrigerator measured a temperature of at least 40 degrees Fahrenheit for appropriate food storage. There is also one (1) coffee maker and one (1) toaster, both in working order. The residential area has a central cooling/heating system. REPORT CONTINUES, SEE LIC809C. Water Temperature: The water temperature is 106.9 degrees F located in the kitchen and water temperature averaged at 105.7 degrees F in the two (2) bathrooms. Medications, First-Aid Kit & Book: A first aid kit is stored in the central closet and was inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to residents. The resident's medications will be stored in a metal cabinet, locked and inaccessible to residents in care, located in the living room area. Resident & Staff Files: The applicant is not handling the cash resources for residents. Records of staff and residents will be stored in a metal cabinet in the dining room area. Reading Material, Games, Equipment & Materials: The facility has board games, books, magazines, and other recreational materials for the resident's use all stored in the living room, below the TV unit. Pool/Jacuzzi & Pets: There are no pets located on-site and the above-mentioned facility does not have any bodies of water on-site. The component III power point was held with Jose Umana and Elsa Roman and both acknowledged the points discussed . An exit interview was conducted with Jose Umana, and a copy of this report has been provided to the applicant. LPA Leon 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.the state’s words, verbatim · CDSS document, Jul 8, 2024

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 - Elsa Roman CEO/ Jose Umana Administrator Interview Method: Telephone interview On June 18, 2024, 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, Jun 18, 2024