Peters Family Home

Type of visit: Required - 1 Year

On 3/20/26 Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required inspection visit using the new CARE Inspection Tool. LPA met with Jadesha Peters as the purpose of today’s visit was explained. The facility is licensed to operate for (5) ambulatory residents ages 60 and above. The facility is approved for (3) hospice residents. The facilities annual fees info. and pin were provided, liability insurance is active (Identity Insurance Services ISCAH0100000358-00 exp: 3/3/27), surety bond is active (Western Surety company 66970565), and the facilities Administrator certificate is current and expires on 3/28/2026. The facility is a single-story home and consists of the following: (4) resident bedrooms, (2) bathrooms, living room, kitchen, dining room, back yard with shaded seating, and an attached garage that houses a washer and dryer, a deep freezer, and is used for storage. A land line was observed. All resident rooms were checked, mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space, walls and floors were clean and in good repair, and bed linens, comforters and bath towels were fully stocked. Bathrooms were found to be within Title 22 regulation, toilets and water faucets worked properly, shower was free of mold/mildew, thre are sufficient toiletries accessible to the residents. The water temperature measured between 105- 120 F. degrees. LPA conducted a records review of (5) residents records, (5) P&I ledgers, (3) Medication Administration Records (MAR), and (3) staff records. No discrepancies observed. (1) fire extinguishers fully charged, carbon monoxide and smoke detectors are interconnected and operational, and the first aid kit was checked and fully stocked. The fire/emergency drill was completed on 3/02/26. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 20, 2026

Type of visit: Required - 1 Year

On 3/14/2025, at 1:00pm, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required inspection visit using the new CARE Inspection Tool. LPA met with Jadesha Peters, Administrator, and explained the purpose of today’s visit. The facility is licensed to operate for five (5) ambulatory residents ages 60 and above. The facility is approved for (3) hospice residents. Currently the facility has (5) ambulatory residents. The facilities annual fees are current. The facility is a single-story home and consists of the following: four (4) resident bedrooms, two (2) bathrooms, living room, kitchen, dining room, back yard with patio and chairs, and an attached garage. LPA conducted a records review of five (5) residents records, three (3) staff records, and reviewed the facility disaster plan. All resident & staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. The fire/emergency drill was completed on 3/04/25. LPA reviewed (5) Resident Medication Administration Records and did not observe any discrepancies at the time of visit. The facilities administrator certificate was current and expires on 3/28/2026. LPA observed that the facility has current liability insurance which expires on 03/03/2026. All resident rooms were checked, mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space, walls and floors were clean and in good repair, and bed linens, comforters and bath towels were fully stocked. Bathrooms were found to be within Title 22 regulation, toilets and water faucets worked properly, shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature measured between 105.1-118.6F degrees. Page 1 of 2 Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke/Carbon monoxide detectors were observed and operational. LPA observed one (1) fire extinguisher that was fully charged; toxins and knives were locked and inaccessible to residents. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked, first aid manual was up to date. A landline was observed. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA further observed the facility to have a 30-day supply of Personal Protective Equipment (PPE). LPA advised the administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues. During today’s visit LPA did not observe any deficiencies. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator, Jadesha Peters. Page 2 of 2the state’s words, verbatim · CDSS document, Mar 14, 2025

Type of visit: Prelicensing

On 02/28/2024 12:52 PM, Licensing Program Analyst (LPA) Regina Cloyd conducted an announced visit to the facility for purpose of a pre-licensing evaluation. An application was submitted to CCLD on 11/15/2023, for an initial license for a Residential Care Facility for the Elderly to serve the elderly for ages 60 years and older. The requested capacity is for five (5) ambulatory only. The facility has a hospice waiver for three (3). Structure: Facility is a (4) bedroom, (2) bathroom, single story house with a (2) car attached garage. The facility has a kitchen, dining room, and living room. The home has a fireplace in the dining room with a metal screen cover and is inaccessible to residents. The residents' bedrooms are spacious and easily accommodate the residents' furnishings. There is a back yard with outdoor furniture and shade and a shed for storage. Passageways, walkways, driveways, steps and backyard are free from obstructions and hazards. Bedrooms: There shall be no more than two residents per bedroom. Bedrooms #1, #2, and #4 is for (1) ambulatory resident. Bedroom #3 is for (2) ambulatory residents. Bedroom #3 has two beds, two chairs, two night stands (with two drawers), and two lamps in addition to overhead lighting. It also has one dresser with five drawers and two closets. Bathrooms: All bathrooms have a working toilet, wash basin, and bathtub/shower. Night lights are in the hallways for bathroom #2. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen is stored in hallway closet. Continue to LIC 809-C Emergency Phone Numbers, Exit Plan & Menu: The Emergency Disaster Plan is posted & readily available for review on the cork board near the front door. Mounted fire extinguisher is located in the kitchen. The facility has a working landline. Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good condition. Knives, cutlery and other sharp kitchen utensils are stored in a locked box in the locked island cupboard. Dishwasher in kitchen properly installed and functioning. Smoke Detectors: Smoke detectors and carbon monoxides are electrical, connected, and operable. Appliances: Stove burners, oven, microwave, washer, and dryer are working. There is one refrigerator in the kitchen. Refrigerator has a measured temperature of 41 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central heating and one thermostat in the dining room. Toxins: Clearing compounds are locked/stored under the kitchen sink and in the garage. Water Temperature: Water temperature tested at 120 degrees. Medications, First-Aid Kit & Book: A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and first aid manual, which are stored in the kitchen, available for staff use but inaccessible to residents. Medication boxes are also stored in the same area. Clients & Staff Files: Applicant has a surety bond for $1,000 to handle cash resources of residents and, cash resources will be locked and stored with P & I Ledger, accessible to designated staff. Records of staff and residents will be stored in a locked cabinet.. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the residents' use, commensurate with the plan of operation. Continue to LIC 809-C. Pool/Jacuzzi & Pets: No bodies of water, pool, jacuzzi, nor pets observed on the property. Fire clearance: Fire Clearance was approved on 01/09/2024. There are no security bars on the windows. Pre-licensing Checklist: Completed by licensee and reviewed by LPA. Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance. An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA 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 applicationthe state’s words, verbatim · CDSS document, Feb 28, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 5 Census (if any clients in care): 0 COMP II Participants: Peters, Jadesha - Applicant/Administrator Interview Method: Telephone interview On 02/01/2024, 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 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, Feb 1, 2024