Capps Care Home

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Mariana Agban conducted a Case Management Visit-Other. LPA contacted the Administrator, Angela Fernandez, and disclosed the reason for the visit. On 05/19/26, Community Care Licensing (CCL) received an updated Fire Safety Inspection Request (STD 850) with the following approved updates. Bedrooms #1 and #2, approved for five (5) non-ambulatory residents. Bedroom#3 for one (1) bedridden resident. Exit interview conducted. A copy of this report was signed and delivered.the state’s words, verbatim · CDSS document, Jun 15, 2026

Allegation investigated: Licensee did not follow proper eviction procedures for resident.

Licensing Program Analyst (LPA) Mariana Agban conducted an initial 10-day complaint visit to investigate the above allegation. LPA met with Administrator Angela Fernando and explained the reason for the visit. At approximately 09:00 am, LPA conducted a physical plant tour. LPA requested copies of pertinent information which includes and not limited to Resident Roster, Resident#1(R1) Physician Report, R1 Admission Agreement, and R1's eviction notice. Regarding the allegation: Licensee did not follow proper eviction procedures for resident. It is alleged that Resident #1 (R1) could no longer remain at the facility because R1 is bed bound and the facility does not have bed bound wavier. It was further alleged that R1’s responsible party was asked to sign a document agreeing to relocate R1 within 60 days. LPA interviewed the Administrator, who stated that R1 attended a physician appointment on 04/23/2026, during which R1’s ambulatory status changed from non-ambulatory to bedridden. (Continue on 9099 C) Unsubstantiated The Administrator stated that she discussed R1’s current health status with R1’s responsible party. As a result, a 60-day notice was issued to the responsible party on 04/30/2026 due to R1 requiring a higher level of care and the facility not having an approved bedridden fire clearance. The Administrator further stated that the facility would assist R1’s responsible party with locating an appropriate placement. The Administrator also reported that the 60-day notice was faxed to Community Care Licensing on 04/30/2026. LPA reviewed R1’s Physician’s Report dated 04/23/2026, which confirmed R1’s bedridden status. LPA also reviewed a copy of the 60-day notice issued to the responsible party. Based on interview conducted and records reviewed, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. LPA discussed the process of obtaining an exception waiver with the Administrator. Exit interview conducted, copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 8, 2026 · control 31-AS-20260502190444

Allegation investigated: Licensee did not conduct a proper assessment of resident

Licensing Program Analyst (LPA) Mariana Agban conducted an initial 10-day complaint visit to investigate the above allegation. LPA met with Administrator Angela Fernando and explained the reason for the visit. At approximately 09:35 am, LPA conducted a physical plant tour. LPA requested copies of pertinent information which includes and not limited to Resident Roster, Resident#1(R1) Physician Report, R1 Admission Agreement, and Preplacement Appraisal. On today's visit, LPA interviewed the Administrator, two (2) residents and attempted for three (3) residents. Regarding the allegation: Licensee did not conduct a proper assessment of resident It is alleged that Resident #1 (R1) has a wound and may require relocation to another board and care facility or placement in a skilled nursing facility. LPA interviewed the Administrator, who denied the allegation and stated that a pre-admission appraisal was completed for R1 on 04/03/2026. LPA reviewed R1’s Physician’s Report dated 09/18/2025, which did not indicate the presence of any wounds at the time of assessment. (Continue on 9099C) Unsubstantiated The Administrator reported that R1 is currently receiving services from a Home Health agency for treatment of a Stage 2 wound. The Administrator further stated that R1’s responsible party was notified of the change in condition and agreed with the plan for R1 to remain in the facility while receiving wound care services. LPA contacted the Home Health agency, which confirmed that R1 has a Stage 2 wound and began receiving services on 04/13/2026. Additionally, interviews conducted with Resident #2 (R2) and Resident #3 (R3) indicated that pre-admission assessments were completed by the Administrator prior to their admission to the facility. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted,copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 17, 2026 · control 31-AS-20260410143900

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Mariana Agban conducted a Pre-Licensing Inspection with Licensee Angela Fernando and Administrator Chita Beltara. A Change in Ownership (CHOW) Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on October 03,2025. A fire clearance was approved on December 2, 2025 for six (6) non ambulatory residents for a total capacity of six. Hospice waiver has been approved for six (6) residents. A tour of the physical plant was initiated at approximately 11:10 am and the following was observed: The facility is a one story building with four (4) bedrooms and two (2) bathrooms. KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives were observed locked in a kitchen drawer. Medications are also locked in one of the kitchen cabinets. LPA observed the fire extinguisher that was serviced on 10/06/25. The fire extinguisher is located in the kitchen hallway. BEDROOMS: There are three(3) bedrooms designated for residents use. All three (3) bedrooms are designated for shared use. One (1) room is designated for staff use. All bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting. BATHROOMS: The facility has two (2) bathrooms for the resident's use. Both bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 109.4 and 110.7 degrees (Continue on 809 C) COMMON AREAS: These included the living room and dining room. The living room was equipped with furniture, a television, tables and chairs. The dining area has a large dining room table to accommodate six (6). There were no visible immediate hazards. LAUNDRY ROOM: The washer and dryer observed to be in good repairs. Laundry room door is kept locked. Toxins and other detergents are also locked and inaccessible to residents. GARAGE: garage is used as extra storage for non-perishable and emergency food supplies and water. There is another refrigerator in the garage for additional perishable food items. Resident Files: LPA conducted a file review of random resident records to ensure compliance of licensing forms. Resident files are kept locked in the living room cabinets. Staff Files: Staff files are also kept in a locked cabinet in the living room cabinet. SURROUNDING GROUNDS: All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a patio and backyard furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space. LPA observed nonfunctional spa that is fenced all around it's parameters. The fence was at least five foot high with a gate, that is also five foot high. Gate was observed locked, making it inaccessible to residents to enter. The gates at both sides of the home were checked to ensure no locks were installed, and that exits and passageways were clear for emergency evacuation. Temperature: Facility maintains a comfortable temperature of 75 degrees Fahrenheit In addition to the Pre-Licensing inspection, a Component III power point presentation was also held. Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 13, 2026