Pleasant Hill Oasis

Type of visit: Required - 1 Year

On 09/10/2026 at 9:30 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Liza Jay Elegado and explained the purpose of the visit. The facility’s fire clearance was approved for all non-ambulatory for capacity of forty-nine (49) residents. Administrator Certificate #7015304740 expires 03/25/2028. LPA toured the facility with Liza Jay including but not limited to three (3) residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 85 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 117.5, 115 and 120 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. LPA reviewed 5 residents records. LPA reviewed 6 staff records and 5 of 6 have current first aid training and associated to the facility. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/17/2026: LIC 308 Designation of Administrative Responsibility - Reviewed LIC 309 Administrative Organization - Reviewed LIC 500 Personnel Report - Reviewed LIC 610E Emergency Disaster Plan - Reviewed Liability Insurance - Reviewed Current Administrator’s Certificate - Reviewed DEFICIENCIES OBSERVED: 11:31 AM missing toilet seat in resident's bedroom 11:36 AM back patio grounds dirty 12:12 PM soiled floors in bathrooms, kitchen areas 12:13 PM tires, trash, debris behind sheds 12:14 PM 4-5 wheelchairs behind building located outside 12:18 PM trees leaves/branches up against building and roof 12:24 PM dining room chairs, tables, wheelchair sitting outside 12:26 PM broken chair located at side gate on the ground 12:27 PM broken window at front meeting room 12:30 PM floor siding broken 12:32 PM insect/pest droppings in cabinet located in bathroom 12:34 PM dirty soiled carpet throughout hallways The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 10, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Sep 11, 2026

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by..county fire department...State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by...city and county fire department.. (2) Bedridden persons This requirement is not met as evidenced by: Based on record review and observation, the licensee did not comply with the section cited above in by not having a fire clearance for bedridden resident, R2, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: Administrator will send LIC 200 w/facility sketch indicating room(s) for bedridden by POC due date. Civil Penalty Assess $500.00

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Sep 24, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in by not having floors clean in kitchen with built grime, hallway carpets, floor siding lifting, baseboards dirty, missing toilet seat, glass window broke, trees/leaves and debris hanging on roof/building in meeting room which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: Administrator agreed to power wash all grounds. Clean all areas listed on report and send photos of all cleaned areas by POC due date. Repeat Violation $250.00

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b)(2) · Plan of correction due date: Sep 24, 2026

87303 Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times.(2) The facility shall cool rooms to a comfortable range...or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in by not having rooms including but not limited to the common areas, television area where thermostat read 85 degrees which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: Administrator will fixed A/C and in the meantime get portable A/C including but not limited to common areas by POC due date.

Type of visit: POC

On 9/02/2026 at 9:30am, Licensing Program Analyst (LPAs) A. Gomez to conduct proof of correction (POC) visit. LPA met with Liza Elegado, Administrator and explained the purpose of the visit. LPA A Gomez issued deficiencies during complaint investigation 15-AS-20260330125931 on 7/14/2026 and the following deficiencies were not corrected: 1569.269(a)(5) on 9/2/2026 LPA toured facility in it entirety and observed dead and alive roaches, bedbugs, and gnats throughout the facility which poses an immediate personal rights risk to persons in care 87303(a) on 9/2/2026 LPA toured facility in it entirety and observed unclean floors in common areas and residents rooms with debris, food, dirt, LPA also observed surfaces in kitchen unclean with dirt, oil, and dead bugs as well as laundry area unclean and disorganized LPA will cite utilizing this regulation Civil Penalties in the amount of $200 is assessed today for the period of 9/1/2026-9/2/2026 for failure to meet POC date for deficiencies $100 for 1569.269(a)(5) and $100 for 87303(a). Facility is subject to ongoing civil penalties until deficiencies are corrected. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 2, 2026

Allegation investigated: Staff do not keep facility free from pests Facility is not clean and sanitary Facility shower are in disrepair

On 7/14/2026 at 2:00 PM, Licensing Program Analyst (LPA), A. Gomez arrived unannounced to deliver complaint findings for the allegations above. LPA met with Executive Director, Liza Elegado and explained the reason for the visit. During the course of the investigation LPA conducted interviews, toured facility, made observations, reviewed compliance history, and reviewed records report continues on LIC9099-C Substantiated On the allegation Staff not competent to provide care LPA reviewed staff training's and observed staff providing care. LPA observed that staff is up to date on their training's and LPA did not observe any improper care being provided. LPA also interviewed R2 who states that they have not had any issues with care therefore the allegation is Unsubstantiated. On the allegation Staff does not treat residents with dignity and respect LPA interviewed R1 who states that S2 spoke to them inappropriately. LPA also interviewed R2 who stated "Staff is good and does not speak inappropriately to residents." R2 also stated that some older residents sometimes get upset with the staff and get "snappy" but that staff do not yell or curse at them when that happens. LPA attempted to interview other residents however they declined. LPA was unable to establish a preponderance of evidence to support the allegation therefore the allegation is Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided. On the allegation Staff do not keep facility free from pests. On 4/3/2026 LPA toured the facility with Business Office Manager (BOM) and observed Bed bugs and roaches throughout facility. LPA requested and reviewed the facilities \pest control plan with BOM. LPA also observed during the visit that facility staff were utilizing heat treatments to help remove bedbugs. LPA observed that the pest control agreement did not show that they were treating for bedbugs. LPA interviewed BOM who stated that they have been utilizing the heat treatments for bedbugs but that the staff administering the treatment are not certified pest control. BOM also states that they have not been able to fully eradicate the bedbugs. LPA also reviewed facilities compliance history and past licensing reports and observed that the pests have been an on going issue for over a year. While at the facility on 7/14/2026 LPA conducted a walk through of the facility and observed an excess of small flying black bugs throughout the facility and on residents beds. LPA also briefly spoke with R1 and R3 who both stated that there has been an on going issue of roaches, bedbugs, and fruit flies/ gnats therefore the allegation is Substantiated. On the allegation Facility is not clean and sanitary On 4/3/2026 LPA toured the facility with Business Office Manager (BOM) and observed unclean floors throughout, black mold growing in common bathroom shower, black mold on ceilings, unclean surfaces and walls, as well as bug carcasses. Also observed through photos received were feces coming out of the drain when shower was in disrepair therefore the allegation is substantiated On the allegation Facility shower are in disrepair LPA received photos from W2 of shower drain with brown water pooled around and it not draining properly. LPA also spoke with executive director who states that there were some repairs done on the shower as it was in disrepair. ED states that a professional plumber came out to fix the shower. plumber therefore the allegation is substantiated Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 14, 2026 · control 15-AS-20260330125931

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.269(a)(5) · Plan of correction due date: Sep 1, 2026

(a) Residents of residential care facilities for the elderly shall have all of the following rights:(5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above having roaches, bedbugs, and gnats throughout the facility which poses an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 14, 2026

Plan of correction: By POC facility agrees to have treatments done as neccesary to completely exterminate all bugs and deep clean the facility of their remains and LPA will return to inspect and complete a POC visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Sep 1, 2026

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above having unclean floors throughout facility, black mold growing in common bathroom shower, black mold on ceilings, unclean surfaces and walls, as well as bug carcasses which poses an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 14, 2026

Plan of correction: By POC facility agrees to deep clean the facility and LPA will return to inspect and complete a POC visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Jul 15, 2026

(d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by: Based on interview and review of photos, the licensee did not comply with the section cited above by the back shower being in disrepair and feces coming from the drain which posed a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 14, 2026

Plan of correction: Facility states that they have already repaired the shower POC clear.

Type of visit: Case Management - Incident

On 06/16/2026 at 12:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit regarding an incident report received by the Community Care Licensing Division (CCLD) on 05/07/2026. LPA met with Executive Director, Liza Elegado, and explained the purpose of the visit. CCLD received an Unusual Incident Report (UIR) on 05/07/2026 indicating that Resident (R1) was discovered missing during rounds conducted at approximately 3:00 AM on 05/06/2026. LPA interviewed Staff (S1), who stated that the incident occurred during the night shift. According to S1, S2 and S3 were on duty at the time of the occurrence. S1 stated that S2 was completing laundry duties while S3 was assisting another resident with a diaper change. S1 stated that during routine rounds, S2 discovered that R1 was not in their bed. S2 and S3 immediately conducted a room-to-room search of the facility but were unable to locate R1. S1 stated that S2 contacted the local police department to report R1 missing. The police department subsequently informed facility staff that R1 had been located and would be transported to the hospital emergency room for evaluation. S1 stated that law enforcement advised facility staff that R1 had sustained a fall. LIC809-C Continued... LIC809-C (Page 2) LPA requested and reviewed copies of R1's Physician's Reports (LIC 602A) dated 02/20/2025 and 06/09/2026, Face Sheet, Appraisal Needs and Services Plan, Staff Caregiver NOC Schedule for May '26, and Skilled Nursing Facility (SNF) discharge notes. Review of R1's LIC 602A, dated 02/20/2025, indicated that R1 was unable to leave the facility unassisted and required "complete supervision." LPA reviewed R1's SNF discharge notes, which indicated that R1 was discharged from the hospital on 05/11/2026 following hospitalization for multifocal pneumonia and a C2 fracture sustained as a result of a fall. The following deficiency was observed and cited during today's visit (see LIC 809-D) in accordance with California Code of Regulations, Title 22. Failure to correct the deficiency by the Plan of Correction (POC) due date may result in additional civil penalties. An exit interview was conducted. Appeal Rights, LIC421M and a copy of this report was provided to Executive Director, Liza Elegado.the state’s words, verbatim · CDSS document, Jun 16, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 30, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1...elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on interviews and record review, the licensee failed to ensure a safe environment for R1, who was assessed as unable to leave the facility unassisted and requiring "complete supervision" per the LIC 602A dated 02/20/2025. On 05/06/2026, R1 was discovered missing from the facility during the night shift and was subsequently located by law enforcement outside the facility after sustaining a fall. This posed an immediate risk to R1's health, safety, and personal rights.the state’s words, verbatim · CDSS document, Jun 16, 2026

Plan of correction: Administrator agreed to conduct an in-service training with all staff on all shifts regarding resident supervision, monitoring, and elopement prevention procedures. The Administrator shall submit a copy of the training materials and participant sign-in sheets to CCLD by the POC due date. The in-service training document shall include a detailed synopsis of the topics discussed, including staff responsibilities for conducting resident checks, responding to missing residents, and ensuring residents requiring supervision do not leave the facility unassisted. In addition, Administrator will update R1's Appraisal Needs and Services and sign with R1 and/or R1's responsible parties. Immediate Civil Penalty for $500.00 is being assessed today.

Type of visit: Case Management - Deficiencies

On 11/18/2025 at 2:25 PM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management. LPA met with Care Supervisor, Delia Perez, and explained the purpose of the visit. Executive Director, Liza Elegado was unavailable. LPA conducted an Annual Inspection on 08/28/2025 and cited for deficiencies. The Plan of Correction (POC) original due dates was 09/12/2025. LPA conducted a POC visit on 10/02/2025 in which there were deficiencies not cleared. Deficiencies not cleared: CCR 87303(a)(1) Repeat Violation. Civil penalty assessed $250.00. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 2:27pm door to medication room was unlocked, door not closed and no one supervising. At 2:50pm cleaning cart located in hallway with Clorox Bleach and other cleaning chemicals left unattended LIC809-C Continued... LIC809-C (Page 2) THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT CONTINUED: At 2:56PM ladder located outside unattended At 2:57pm wood located outside by a shed At 2:59pm long cylinder object laying next to fence on side yard At 3:00pm cigarette butts located outside on the grounds At 3:00pm two (2) bicycles located outside At 3:01pm floors dirty The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report, LIC421FC and appeal rights providedthe state’s words, verbatim · CDSS document, Nov 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Nov 19, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. Based on observation, the licensee did not comply with the section cited above in by not having the medication room door locked, unopened and left unattended by staff which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 18, 2025

Plan of correction: Administrator will conduct In-Service training with Med Techs/Staff on keeping medications safe/locked and inaccessible to residents. Submit participant sign-in sheet with topic summary to CCLD by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Nov 19, 2025

87309 Storage Space and Access (a) Except...(b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, ...and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. Based on observation, the licensee did not comply with the section cited above in by not having Clorox Bleach and other cleaning disinfectants inaccessible to residents and unattended by staff which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 18, 2025

Plan of correction: Administrator will conduct In-Service training with Staff/Housekeeping Staff on keeping disinfectants, cleaning solutions, poisonous substances inaccessible to residents and left unattended by staff. Submit participant sign-in sheet with topic summary to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Nov 25, 2025

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in by not having the residents' bathrooms clean including but not limited to the floors, toilets, sinks, bedroom floors, the kitchen, the hallway carpets deep cleaned with dirt spots, floor molding cleaned outside with cigarette butts laying on the grounds (front/side/back yards), garbage, bicycles, ladder, wood, cyclinder objects which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 18, 2025

Plan of correction: Administrator will create a detail plan and schedule on cleaning, keeping the grounds clean, maintenance and ensuring that repairs are maintained and completed. Submit photos of areas cleaned and detail plan to CCLD by POC due date. Repeat Violation civil penalty $250.00

Type of visit: POC

On 10/02/2025 at 2:15 PM, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Plan of Correction (POC) visit and met with Executive Director, Liza Elegado. LPA explained the purpose of the visit to the Executive Director. LPA conducted an annual inspection on 08/28/2025 during which the facility was cited for deficiencies. LPA was unable to return for the Plan of Correction visits with due dates of 09/11/25, 09/12/25, 09/15/25, 09/19/25, and 09/25/25. Deficiencies not cleared by today’s visit will be re-cited, and civil penalties will be assessed for failure to correct in a timely manner. Deficiencies Cleared: CCR 87411(f) CCR 87303(i)(1)(A) CCR 87303(c) CCR 87506(a) CCR 87463(a) LIC809-C Continued LIC809-C (Page 2) Deficiencies Not Cleared: CCR 87303(a)(1) – Maintenance and Operation (Buildings and Grounds) Repeat violation. During inspection, LPA observed that the facility had not repaired/maintained required physical plant conditions to ensure the health and safety of residents. Civil Penalty $250.00 CCR 87463(h)(1) – Reappraisal Requirement Facility did not provide updated reappraisals for residents. However, appointments for residents are pending. LPA granted an extension to 10/25/25 new due date. An exit interview was conducted. A copy of this report, LIC421FC, and appeal rights were provided to the Licensee.the state’s words, verbatim · CDSS document, Oct 2, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Oct 16, 2025

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in by not having the residents' bathrooms clean including but not limited to the floors, toilets, sinks, bedroom floors, the kitchen, the hallway carpets deep cleaned with dirt spots, floor molding cleanedoutside with cigarette butts laying on the grounds (front/side/back yards), garbage on the grounds, plastic gloves, old boxes, shrubbery/branches which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 2, 2025

Plan of correction: Administrator agreed to clean, sanitized all areas and maintain all areas with a daily/weekly/monthly schedules of all areas and discuss/meet with all maintenance and housekeepers on complying and maintaining the cleaniliness, sanitazion and repairs of the facility. Administrator will submit photos to CCLD by POC due date. Repeat violation $250.00

Type of visit: Required - 1 Year

On 08/28/2025 at 12:15 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Liza "Gigi" Elegado and explained the purpose of the visit. The facility’s fire clearance was approved for forty-nine (49) residents; all may be non-ambulatory. Hospice waiver approved for ten (10). Administrator Certificate# 7015304740 Expires 03/25/2026. LPA toured the facility with Liza including but not limited to two (2) residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 81 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 123, 124 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. LPA reviewed 10 (ten) residents records. LPA reviewed eight (8) staff records and 7 of 8 have current first aid training and associated to the facility. LIC809-C Continued... LIC809-C (Page 2) THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 5:27pm LPA observed washing machines and bulky items located in a trailer and a broken mini refrigerator and table in parking lot At 5:30pm LPA observed window screen off window and dirty windows, and dirty dusty window blinds in the facility At 5:33pm LPA observed a ladder and garden tool outside Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/04/2025: LIC 308 Designation of Administrative Responsibility - Reviewed LIC 309 Administrative Organization - Reviewed LIC 500 Personnel Report - Reviewed LIC 610E Emergency Disaster Plan - Reviewed Liability Insurance - Reviewed Current Administrator’s Certificate - Reviewed The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report providedthe state’s words, verbatim · CDSS document, Aug 28, 2025

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: Resident sustained unexplained injury while in care. Resident's hygiene needs are not being met. Staff did not ensure that the resident had clean clothes. Staff does not provide resident with appropriate bed linens.

On 03/12/2025 at 10:30 AM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Executive Director, Liza Elegado, to deliver the findings of above allegations. LPA explained the purpose of the visit with Executive Director. During investigation, the Department obtained the following documents from the facility – Physician's Reports, Needs and Services Plans, Resident Roster, Staff Roster, Narrative Charting, After-Visit Summaries, Admission Agreements, Pre-Placement Appraisals, Resident Assessment, MAR, Outside Agency/Services Documentation and Identification and Emergency Information. LIC9099-C Continued... Unsubstantiated LIC9099-C (Page 2) Allegation: Resident sustained unexplained injury while in care. Finding: Unsubstantiated On 06/11/2024, LPA interviewed Witness (W) W1. W1 stated that resident (R) R1’s neck appeared to be swollen and that R1 had tears in their eyes. W1 stated that it took R1 a long time to look up, there was dried up blood on R1’s face and they were also wearing a mask. LPA interviewed R1. R1 stated that they haven’t had any injuries, falls, been hurt or felt any pain and that no one has hurt them while at the facility. Allegation: Resident's hygiene needs are not being met. Finding: Unsubstantiated On 06/11/2024, LPA interviewed W1. W1 stated that when they visited R1 they didn’t look clean. LPA interviewed R1 and R1 stated that they take showers and brush their teeth. LPA interviewed R1 that stated that they do take showers every week. LPA reviewed the Shower Schedule (as of 04/18/2024) and it shows that R1 is scheduled a shower 2 times a week on Sundays and Thursdays. Allegation: Staff did not ensure that the resident had clean clothes. Finding: Unsubstantiated On 06/11/2024, LPA interviewed W1. W1 stated that R1’s clothes didn’t look clean and that their jacket looked like it was on the ground. LPA reviewed the “Laundry Day of Residents,” that showed R1’s laundry day is scheduled on Saturdays in the LIC9099-C Continued... LIC9099-C (Page 3) A.M. LPA interviewed R1 and R1 stated that their clothes get laundered weekly. LPA observed that R1 had clean clothes hanging in their closet and appeared clean during visit. Allegation: Staff does not provide resident with appropriate bed linens. Finding: Unsubstantiated On 06/11/2024, LPA interviewed W1. W1 stated that 3 weeks back R1 had a white blanket, a tarp and a flat sheet on their bed. LPA interviewed staff and S1 and S2 stated that all residents have bed linen sheets, blanket and bed spread/comforter on their beds. LPA observed flat and fitted sheets along with a blanket on R1’s bed. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 15-AS-20240605154741

Allegation investigated: Licensee does not ensure the facility is free of roaches. Licensee does not ensure community toilet is in good repair.

On 03/12/2025 at 12:30 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Executive Director, Liza Elegado, to deliver the findings of above allegations. LPA explained the purpose of the visit with Executive Director. During investigation, the Department obtained the following documents from the facility – Resident Roster, Staff Roster, Staff Schedules for January '25, Menu for Week 2, and Terminix Pest Control Agreements (12/26/24, 01/09/25). LIC9099-C Continued... Substantiated LIC9099-C (page 2) Allegation: Licensee does not ensure the facility is free of roaches. Finding: Substantiated On 01/22/2025, LPA interviewed witnesses (W) W1. W1 stated that they have seen roaches crawling on the walls. W1 stated that they also saw a roach on the mattress. W2 stated that while at the facility on 12/09/2024 they observed a can of roach spray in one of the rooms. LPA interviewed residents (R). R1, R2, R3 all stated that they have seen roaches and bed bugs at the facility. LPA observed a dead roach that R1 showed them in a napkin. R1 stated that there is bed bugs at the facility and that they saw bed bugs on their bed. R2 stated that they saw bed bugs in their room and that they got their sheets changed that morning. On 01/22/2025, LPA interviewed staff (S). S1 stated that they have called pest control company, Terminix, out to do a treatment. LPA reviewed and obtained a copy of the Terminix contract. On 03/12/2025, LPA interviewed S1 that stated they changed to a different new pest control company that will do a different type of treatments for the roaches. During visit, LPA observed a roach crawling on the glass indoor window and technician completing a pest inspection and treatment. W3 stated that they did not find any bed bugs, but did find German roaches in one of the residents' room. LPA obtained a copy of Pest Management Service Agreement. LIC9099-C Continued... LIC9099-C (Page 3) Allegation: Licensee does not ensure community toilet is in good repair. Finding: Substantiated On 01/22/2025, LPA interviewed W1. W1 stated that the toilet in the community area is not anchored and the toilet moves. LPA observed the toilet and saw that the toilet is not properly anchored on the floor. LPA addressed the issue with S4 that stated the toilet would get fixed. On 03/12/2025, LPA interviewed S2 that stated awareness of the toilet moving. S2 stated that R1 showed them that the toilet was moving because R1 is strong and moved the toilet. LPA went to community bathroom located in main hallway and observed that the same toilet observed on 01/22/25 was still not anchored and was sliding on the floor. Based on LPA's observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided. LIC9099 (Page 4) Allegation: Licensee does not provide adequate food service for residents. Finding: Unsubstantiated On 01/22/2025, LPA interviewed W1. W1 stated that the kitchen is disgusting. The dishes are dirty with food scraps and dishwasher is dirty. R1 stated that there is not enough food. R1 stated that they get served noodles and may get snacks. R1 stated that they have lost a lot of weight. R2 stated that the facility serves food that is heavy on carbs. R2 stated that they have to ask for more salad, the food is served “luke” warm and that they get snacks. R3 stated that they get served snacks, juice, decaf coffee and cookies. R4 and R5 stated that they get served hot soup, eggs, toast and orange slices like two times a week. On 03/12/2025, LPA interviewed S3. S3 stated that they serve the residents breakfast, lunch and dinner. S3 has a list of residents that are on a modified diet. S3 stated that meals are prepped on plates which are served on trays. Trays are delivered to each resident in their rooms. S3 stated that some residents prefer their food hot and some prefer their food warm. S3 further stated that they have microwaves in the dining room and kitchen and if the residents like their food hot they can ask to have food microwave. LPA interviewed R6 that stated they are served their meal, sometimes the food is cold when it should be served hot. R6 stated that he is served an adequate portion and knows that there are microwaves to warm up food if he asks the caregivers. LPA observed during visit that the kitchen prepared ham, potatoes and mixed vegetables to be served for dinner. LIC9099-C Continued... LIC9099-C (Page 5) Allegation: Staff does not ensure resident has clear access to toilet in room. Finding: Unsubstantiated On 01/22/2025, LPA interviewed W1 that stated R6's toilet riser is not accessible and that R6 has to yell for help. On 03/12/2025, LPA interviewed R6 that stated they have no problems with their bathroom, accessing the toilet, and the toilet riser is ok. Allegation: Licensee does not ensure one employee is on duty and on the premises awake during night supervision. Finding: Unsubstantiated On 01/22/2025, LPA interviewed W1. W1 stated that at night sometimes there is only one (1) caregiver and that they are sleeping by midnight. On 03/12/2025, LPA interviewed R7, R8, R9, and R10 and all stated that they have not observed any caregiver on NOC shift sleeping. R7, R8, R9 and R10 all stated that there is more than one (1) caregiver during the NOC shift. LPA interviewed S1 that stated they have come to the facility around 3:00 AM in the morning to conduct in-service training and have not observed any staff sleeping. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 15-AS-20250115141818

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80087(a)(1) · Plan of correction due date: May 28, 2025

80087 Buildings and Grounds (a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement is not met as evidenced by: Based on interviews and observations, the licensee did not comply with the section cited above in by having roaches in the facility and residents' bedrooms which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 12, 2025

Plan of correction: Administrator agreed to submit a copy of pest inspection reports and contract agreements for the months of March, April and May to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 9, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on interviews and observations, the licensee did not comply with the section cited above in by not having the toilet properly anchored to the floor including but not limited also the flooring and toilet area shall be clean and sanitized which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 12, 2025

Plan of correction: Administrator agree to repair toilet and submit repair invoice along with photos of toilet repaired, anchored and floors sanitized clean to CCLD by POC due date.

Allegation investigated: Staff did not accord resident dignity in personal relationships with staff. Staff did not return resident’s laundry in a timely manner. Staff spoke to resident in an inappropriate manner.

On 03/12/2025 at 11:30 AM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Executive Director, Liza Elegado, to deliver the findings of above allegations. LPA explained the purpose of the visit with Executive Director. During investigation, the Department obtained the following documents from the facility – Physician's Report, Needs and Services, Doctor's Order, MAR for R1. In addition, LPA requested LIC 500, and Laundry Schedules. LIC9099-C Continued... Unsubstantiated LIC9099-C (Page 2) Allegation: Staff did not accord resident dignity in personal relationships with staff. Finding: Unsubstantiated On 10/17/2024, LPA interviewed witness (W) W1. W1 stated that they didn't know what was going on. LPA interviewed staff (S). S1 stated that resident (R) R1 gets confused. R1 was not available for interview. Allegation: Staff did not return resident’s laundry in a timely manner. Finding: Unsubstantiated On 10/17/2024, LPA interviewed W1. W1 stated that S2 doesn’t return laundry back. LPA interviewed S1. S1 stated that they directed S2 and all male caregivers to not enter resident’s room. S1 stated that laundry was being done during the NOC shift. S1 stated that the laundry will be delivered the following day in the mornings by female caregivers. Allegation: Staff spoke to resident in an inappropriate manner. Finding: Unsubstantiated On 03/12/2025, LPA interviewed S1. S1 stated that they will never speak or talk to any of the residents out of anger. However, S1 stated that their voice is firm to keep control of all the situations and S1 stated that the residents respect them. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 15-AS-20241016154807

Allegation investigated: Staff did not follow the directives of resident's doctor. Staff are not able to effectively communicate with residents.

On 03/12/2025 at 3:30 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Executive Director, Liza Elegado, to deliver the findings of above allegations. LPA explained the purpose of the visit with Executive Director. During investigation, the Department obtained the following documents from the facility – Resident Roster, Room Assignment, Staff Roster including, but not limited to the following; Personnel records: Nurse & Med. Techs. training records. Resident #1 (R1) records: LIC602, Resident Preplacement Appraisal, Move in Records - ID/Emergency contact information, Medication lists, MARs and After Visit Summary. LIC9099-C Continued... Unsubstantiated LIC9099-C (Page 2) Allegation: Staff did not follow the directives of resident's doctor. Finding: Unsubstantiated On 03/11/2025, LPA interviewed witness (W). W1 stated that resident (R) R1 told them that they were given a medication before their scheduled surgical procedure and was not supposed to take that medication. On 03/12/2025, LPA interviewed staff (S). S1 stated that there were no doctor's orders instructing the Med Techs to not administer the medication. S1 stated that they were not informed by R1 that they were having a procedure until the day before. S1 stated that R1 will not give them any copies of doctor's orders or After Visit Summary when they are seen at the doctor or Emergency Room (ER). S1 stated that R1 is their own responsible party. LPA reviewed the latest Physician's Report (LIC602-A) that indicates R1 is able to administer own prescription medication with an explanation, "but may need reminders." S1 stated that they called and spoke with the nurse care coordinator to get clarification and advised that the LIC602-A was not appropriate. S1 stated that R1 has an scheduled appointment with their primary care physician in April and will get the physician's report updated regarding medications and if they are able to leave the facility unassisted. LIC9099-C Continued... LIC9099- C (Page 3) Allegation: Staff are not able to effectively communicate with residents. Finding: Unsubstantiated On 03/11/2025, LPA interviewed W1 that stated R1 told them that the caregivers do not speak English. On 03/12/2025, LPA interviewed S1 that stated all staff caregivers speaks English except for maybe one person. S1 stated that the caregiver speaks Spanish and that they use a translator on their phone to communicate. S1 stated that every shift including the NOC shift has at least one (1) caregiver that speaks English. S1 stated that the caregiver that speaks Spanish does know how to communicate in terms of giving care to the residents. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 15-AS-20250214143406

Allegation investigated: Personal Rights

On 01/09/2025 at 10:30 AM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Executive Director (ED) to deliver the findings of above allegation. LPA explained the purpose of the visit with Executive Director, Liza Elegado. During investigation, the Department obtained the following documents from the facility – Physician’s Report, Admission Agreement, Preplacement Appraisal, Medication Administration Record (MAR), Case notes, Incident Reports, Emergency and Identification Information, Home Health Notes, Hospice notes, Appraisal Needs and Services Plan, Hospital Discharge, Personnel Report (April 2022), Service Request, Resident Assessment and Psychiatric Progress Notes, Power of Attorney, Death Report and Death Certificate. LIC9099-C Continued... Unsubstantiated LIC9099-C Continued... Allegation: Questionable Death Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s medical documents showed that on 01/07/2022, R1’s primary diagnosis was unspecified depressive disorder. On 01/27/2022 R1 had an ER visit at Contra Costa Regional Medical Center for nicotine patch and redness in right ear. On 04/27/2022 Staff (S1) received a radio call approximately 1145-1300 that there was an emergency in R1’s room. S1 stated that they found R1 unresponsive while S2 was performing the Heimlich Maneuver. S1 stated that they began giving Cardiopulmonary Resuscitation (CPR) and dialed 911. S1 stated that Paramedics arrived and continued emergency resuscitation. S1 stated that R1 was admitted at John Muir Medical Center in Walnut Creek, CA. Per review of subject resident’s Needs & Services and interview resident was independent in eating and not a choking risk. Review of documents reports that R1 passed away on 05/04/2022 at 1312. Documents obtained do not suggest R1’s death was a result of neglect or lack of care for suspicious circumstances from facility staff. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of questionable death and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation of questionable death is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 9, 2025 · control 15-AS-20230418112239

Type of visit: Case Management - Deficiencies

On 01/09/2025 at 11:49 AM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management. LPA met with Executive Director (ED), Liza Elegado, and explained the purpose of the visit. LPA L. Alexander conducted an Annual Inspection on 10/08/2024 and cited for deficiencies. The Plan of Correction (POC) original due dates was 10/09/2024, 10/24/2024, 10/25/2024, 10/31/2024, 11/08/2024 and 11/15/2024. LPA conducted a POC visit on 11/01/2024 in which there were deficiencies not cleared. Deficiencies cleared today: CCR 87355(e)(3) CCR 87623(b)(2)(B) CCR 87411(f) CCR 87303 (a) HSC 1569.618(c)(3) HSC 1569.625 (b)(2) Deficiency not cleared today: CCR 87458(c) The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 9, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(c) · Plan of correction due date: Feb 6, 2025

(c) The licensee shall obtain an updated medical assessment when required by the Department. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in by having Physician's Reports that were over a year old and not updated for R1-R2 which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2025

Plan of correction: Administrator agreed to submit updated Physician's Reports (LIC602A) for R1 and R2 to CCLD by POC due date. Immediate Civil Penalty for $250.00 is being assessed today for repeat violation.

Type of visit: POC

On 11/01/2024 at 9:30 AM, Licensing Program Analysts (LPAs) L. Alexander and D. Doidge arrived unannounced to conduct a Plan of Correction (POC) visit. LPAs met with Business Office Manager, Reynaldo "Jun" Gutierrez and explained the purpose of the visit. Jun called the Executive Director, Liza Elegado to inform. Liza arrived shortly after. On 10/08/2024, LPA conducted an Annual visit in which deficiencies were cited. The POC due dates was 10/24/24, 10/25/24, 10/31/24, 11/08/24 and 11/15/24. Administrator failed to submit the POC by the due dates and this is why LPAs came to make a POC visit. Deficiencies cleared: 87555(b)(16) 87463(a) 87506(a)(b) 87458(b)(1) 87211(a)(1) Deficiencies not cleared: 87211(a)(1) = $100 X 6 = $600.00 87458(C) = $100 X 1 = $100.00 Civil Penalties in the total amount of $700.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing daily civil penalties until deficiencies is corrected. Exit interview conducted. A copy of this report, appeal rights provided and LIC421FC provided.the state’s words, verbatim · CDSS document, Nov 1, 2024

Type of visit: Required - 1 Year

On 10/08/2024 at 11:05 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Liza "Gigi" Elegado and explained the purpose of the visit. The facility’s fire clearance was approved for 49 Resident capacity in which all may be non-ambulatory. Approved hospice waiver for 10 Residents. LPA toured the facility with Gigi including but not limited to 4 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 76 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 105 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. LIC809-C Continued... The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 3:20pm, chairs and chest dresser drawer outside At 3:25pm, cracked siding and flooring in hallway common area and outside resident's rooms At 3:29pm, broken wood and metal on the west side of building outside At 3:30pm, Shop-Vac, dryer/washing machine, upholstered recliner chair outside near front entrance Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/24/2024: LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Updated Facility Sketch Liability Insurance Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Oct 25, 2024

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by: Based on file review, the licensee did not comply with the section cited above in by not having updated Appraisal Needs and Services (ANS) for R2-R9 which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: Administrator will submit self-certification that ANS was updated for R2-R9 and placed in their files to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87623(b)(2)(B) · Plan of correction due date: Oct 31, 2024

87623 Indwelling Urinary Catheter (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (2) Ensuring that the bag and tubing are changed by an appropriately skilled professional should the resident require assistance. Based on observation, interview and file review, the licensee did not comply with the section cited above in by not having documentation of the foley catheter for R7 and R9 in their files including but not limited with a home health care plan, updated Appraisal Needs and Services (ANS) Plan, In-Training staff roster if applicable for whom is caring for the catheter bag which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: Administrator will submit an exception letter for R7 and R9 with supporting documents that includes but not limited to a Physician's Report (LIC602A), Home Health Care Plan, ANS, and staff that was trained by an appropriate licensed health professional to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 25, 2024

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Based on record review and interview with staff, the licensee did not comply with the section cited above by not sending notification (LIC624) to Licensing when R6 was hospitailzed which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: Administrator will read the regulation and self certify that they understand this regulation moving forward.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(c) · Plan of correction due date: Oct 31, 2024

(c) The licensee shall obtain an updated medical assessment when required by the Department. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in by having Physician's Reports that were over a year old and not updated for R2, R3, R4, R6, R7 and R9 which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: Administrator agreed to schedule doctor's appointments and submit copies of updated LIC602A to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.618(c)(3) · Plan of correction due date: Nov 15, 2024

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in by not having First Aid and CPR training certificates updated for S3-S9 which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: Administrator agreed to submit First Aid and CPR training certificates for S3-S9 to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(f) · Plan of correction due date: Nov 15, 2024

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not having health screening and TB test for S3 and S9 and TB test for S7 which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: Administrator agreed to obtain health screenings and negative TB test results for S3 and S9 and a negative TB test for S7 and submit copies to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: Nov 15, 2024

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Based on file review, the licensee did not comply with the section cited above in by not having annual trainings on file and completed for S2-S9 which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: Administrator agreed to send a detailed plan to CCLD on how they will complete the trainings and send the transcripts/certificates of the completed trainings for S2-S9 to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(b)(1) · Plan of correction due date: Oct 24, 2024

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in by not having on file an negative TB result for R5 which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: Administrator agreed to submit an negative TB result for R5 to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a)(b) · Plan of correction due date: Oct 31, 2024

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. (b) Each resident’s record shall contain at least the following information: This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in by not having on file a complete resident file for R6 including but not limited to Admission's Agreement, Physician's Report, consent form, Personal Rights, appraisal, Emergency/ID info. and medication list which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: Administrator agreed to complete the resident file for R6 and submit a copy of all documents to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a)(1)(c) · Plan of correction due date: Nov 8, 2024

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. (c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in by having chest drawer furniture, chairs, ladders, wood, washing machine, recliner, wood loctaed in the front/side/back yards. Flooring in common areas including but not limited to the main hallway was not clean and in disrepair where there are cracks and edges missing/cracked. The floors in the kitchen, bathrooms, resident rooms were not clean and windows/window screens were not clean which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: Administrator agree to submit a detailed plan on how the repairs will be done and submit photos to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(16) · Plan of correction due date: Oct 31, 2024

87555 General Food Service Requirements (b) The following food service requirements shall apply: (16) In facilities licensed for sixteen (16) to forty-nine (49) residents, one person shall be designated who has primary responsibility for food planning, preparation and service. This person shall be provided with appropriate training. This requirement was not met as evidenced by: Based on file review, Licensee did not comply with the section cited above in by having an updated Food Service certification on file for S4, the certificate expired in 2021 which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: Administrator agreed to submit an updated Food Safety certificate for S4 to CCLD by POC due date.