Quartz Haven

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with Dunhill Tolentino for a Required One (1) Year visit. LPA explained the reason for the visit. LPA spoke with the administrator, Madeliene Ayllon, and she designated Dunhill to sign and accept the report. A tour of the physical plant was conducted at around 12:30 PM and the following was noted: The facility has outdoor furniture with a covered shaded area for residents and visitors. It does not have a swimming pool/body of water. This is a single-story property with a total of three (3) shared bedrooms for residents, one (1) bedroom for staff, and two (2) bathrooms. The facility is fire cleared for six (6) non-ambulatory, of which six (6) may be bedridden and a hospice waiver for five (5). The facility is currently occupying six (6) residents. The living room and dining room are neat and clean. The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. (continued on LIC 809-C) Knives and sharps are observed to be locked and inaccessible to residents. Laundry detergents, cleaning agents and other toxins are locked away. The facility maintains a comfortable temperature at 78°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the kitchen and observed to be fully charged and last inspected 03/08/2026. The hot water temperature was measured at 113.1°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. LPA observed medication to be locked and inaccessible to residents. Facility maintains a complete first aid kit. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Aug 7, 2026

Type of visit: Required - 1 Year

On 7/28/2025, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct a required Annual Inspection. Upon arrival LPA was greeted by the Caregiver Dunhill Tolantino, who granted access to the facility. LPA introduced herself by showing her department badge and explained the reason for the visit. The facility Administrator was contacted by phone. LPA Khurshudyan reviewed the required postings on a wall throughout the facility. The inspection tool was used to complete today's visit. At 9:45am LPA, with the help of the caregiver, began a physical plant tour of the facility and the following was observed: This is a single-story building with four (4) bedrooms, two (2) bathrooms, kitchen, garage, common areas, and outdoor areas. This facility is a Residential Care Facility for the Elderly (RCFE). A fire clearance was approved for six (6) Non-Ambulatory residents and one (1) Bedridden resident. The facility also has Hospice waiver for three (3) residents. The smoke alarms and carbon monoxide detectors are hard wired and inter-connected; they were tested and are operational. The facility has two (2) fire extinguishers that were last service on 3/10/2025: the first one is located by the entrance, on the wall, and the second one is located inside the bedroom #2. Kitchen: LPA observed a seven-day supply of non-perishable food, and a two-day supply of perishable food properly stored and labeled. No expired food was observed. Facility stores knives and sharps under the sink inside the locked cabinet. An emergency supply of food / water was stored inside the kitchen cabinets and pantry. Food storage and preparation areas are clean and inaccessible to pests. A weekly menu was also available for clients. Continue on LIC809-C Bedrooms: There are four (4) bedrooms in the facility, of which three (3) are designated for clients use and one (1) bedroom for staff use only. Residents’ bedrooms are shared. LPA observed bedrooms to be properly furnished with beds, linens, night stands, chairs, drawers, closets, and adequate lighting. All bedrooms appeared organized and clean. Common Areas: These include living and dining areas. LPA observed dining, living areas clean and clear of clutter. Furniture is generally new and in a good repair. Dining and living room furniture sits at the capacity of the facility. Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:20am, LPA measured the room temperature to be 74 degrees Fahrenheit. There is a linen closet with an adequate supply of fresh linens ready to use. No obstructions and or tripping hazards found throughout the facility. Facility has landline, LPA checked it was operational. There is a television, cabinet for activities, books and art supplies available for clients’ use. Bathroom: There are two (2) bathrooms in the facility. The bathrooms contained hand soap, paper towels, toilet paper and trash bins with lids. The hot water temperature was measured at approximately 11:05am to be 111.7 degrees Fahrenheit. LPA also observed required signs on the bathroom walls and non-skid mats inside the showers. Garage: LPA observed the garage is attached to the facility and is currently being used as storage for PPE supplies and for emergency water. Laundry Room: Functioning washer and dryer located adjacent to kitchen area inside the locked closet. The laundry detergents and other chemical supplies are also locked inside the closet and inaccessible to clients in care. Backyard: LPA observed sufficient yard space and fenced backyard. Appropriately covered shaded area available for clients to rest. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. Exit doors were unlocked and free of obstructions. There is no body of water in the property. Continue on LIC809-C Staff/Client File review: Facility records are kept inside the locked cabinets located between the kitchen and dining areas. Between 11:15am -12:00pm LPA conducted records review of four (4) staff files and five (5) residents’ records. Files were complete and updated. Medications: At approximately 12:05pm. LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. The facility also maintains Medical Administration Records (MAR). LPA observed centrally stored medications locked inside the kitchen cabinet and inaccessible to clients in care. Complete First-aid kit is also located in the same kitchen cabinet, new manual for first aid kit was also available. No potentially dangerous items were found in the facility. The facility operates with two (2) shifts and has two / three staff members for each shift. All residents were present during the visit, LPA attempted to interview all residents and the Caregivers. Facility plan/sketch is posted on the entrance wall along with other posting requirements. LPA collected LIC500, LIC9020, and the Liability Insurance Certificate copy The Administrator's certificate - Exp date is 2/13/2027. Liability Insurance - Expires 07/22/2026. LPA informed the Administrator that License Annual Fee is past due: Due date was 7/16/25 for the amount $495.00. LPA also provided the PIN 667713 for online payment. No citations issued during today's visit. Exit interview conducted. Copy of this report provided.the state’s words, verbatim · CDSS document, Jul 28, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gary Tan, initially met with staff Dunhill Tolentino for a One (1) Year Required visit for this facility. Mr. Tolentino called the administrator and purpose of the visit was stated. Administrator Medelyn Ayllon designated Mr. Tolentino to sign the report. There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. A tour of the physical plant was conducted with the administrator at 12:35 PM. The facility is a single storey building with four (4) bedrooms and two (2) bathrooms currently occupying five (5) residents. One (1) additional bedroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, all of which may be bedridden. Hospice waiver for three (3) residents. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with dining The facility maintains a comfortable temperature at 76°F. The smoke detectors are hardwired and inter connected and observed to be operational. The fire extinguishers were filled and last inspected on 03/21/24. The facility is equipped with fire sprinkler system. (continued on LIC 809-C) The backyard of the facility has outdoor furniture, with a covered shaded area for clients. The front and backyard passageways were clear of any obstruction. There is no body of water in the facility. There is no garage at the facility, only driveway at the front. Laundry area is located adjacent to the kitchen. Laundry area was observed to be locked. Laundry detergents are locked in the laundry area. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies including detergents and pesticides and other toxins are stored in a locked cabinet below the sink. Knives and sharps are observed to be kept in a locked drawer in the kitchen. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at a range of 111.5°F to 113.7°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the linen cabinet. Medications: LPA observed the medication cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. First aids kits have complete tools and supplies. Client records: Client records are reviewed. Resident #1 (R1) has no admission agreement and medical assessment on file. Resident #2 (R2) has a diagnosis of dementia and no current medical assessment on file. Staff records: LPA conducted a complete file review of staff record. Disaster drill was last conducted on 07/01/2024. Required posting are observed to be complete and current and displayed properly at the facility. Exit interview conducted and copy of this report issued.the state’s words, verbatim · CDSS document, Aug 11, 2024

Allegation investigated: Staff did not ensure that residents were provided with activities

At 9:30 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent visit to deliver final findings. LPA met with the House Manger, Dunhill Tolentino, and disclosed the reason for the visit. To investigate the allegation above, LPA conducted an initial complaint visit on 12/21/2023, interviews and record reviews were made. At 10:18 am, LPA requested resident, staff roster, and Administrator's certificate. At 10:30 am, LPA requested copies of pertinent information which include, but not limited to facility infection control plan, food services trainings, activities list, physician's report, appriasal needs and services plan, and etc. relevant to the investigation. At approximately 10:45 am, LPA conducted a physical plant tour with Licensee. Between 11:00am – 1:00 pm, LPA interviewed the Licensee, one (1) staff and four (4) out of five (5) residents, who were able to communicate. Continue on LIC 9099C Substantiated Staff did not ensure that residents were provided with activities It is alleged that the staff did not provide residents with activities. LPA conducted interviews with four (4) out of five (5) residents who are able to communicate, Licensee and one (1) staff member, and as well as LPA’s observation at the time of the visit to ensure activities are being held. Information from interviews revealed that since the onset of Covid-19 the facility activities routine changed. Interviews with residents did not show that the facility conducts bingo, exercise, coloring, music, etc. Interview with Licensee and staff revealed that the facility does not provide or offer that many activities since the residents do not seem interested in doing anything. During the initial visit between 9:45 AM to 3:00 PM, LPA did not observe any activities being offered to residents in care. Based on the information obtained through interviews and observation this allegation is deemed to be SUBSTANTIATED at this time. Staff made inappropriate comments about resident while in resident’s presence To investigate this allegation, LPA conducted an interview with the Licensee and staff # 1 (S1) and was informed that the staff always takes care of all residents with dignity and respect. LPA was also informed that facility conducts monthly meetings with all staff regarding the basic services, personal rights, mandated reporter, ect. LPA conducted review of all training documents and confirmed the training is being conducted and completed. In addition, four (4) out of five (5) interviewed residents that the facility staff always treats them with respect and they do not have any concerns regarding this allegation. Based on information obtained through interviews there is not enough sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time. Staff prepared resident meals in an unsanitary manner To investigate this allegation, LPA reviewed the infection control plan and toured the facility kitchen. The kitchen was clean and sanitary. LPA conducted interviews with four (4) out of five (5) residents, one (1) staff, and the Licensee. Residents interview confirmed that the food is always clean and sanitary. They never witnessed food being prepared in unsanitary manner. Staff and Licensee interview confirmed that they always prepare food in a sanitary manner. LPA was able to observe the end of breakfast and lunch being served during the visit on 12/21/2023. LPA observed that (S1) is wearing gloves and a mask while prepare and serve food to residents. Based on information obtained through interviews there is not enough sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Feb 22, 2024 · control 31-AS-20231214102926

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a)(i) · Plan of correction due date: Mar 1, 2024

Planned activities (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation.......activities. The activities: (i) facilities shall provide sufficient equipment and supplies..... Based on LPAs observation and staff interview, the licensee did not comply with the section cited above by not providing or offering activities to residents in care which poses/posed a potential health, safety to persons in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Licensee shall maintain a log of all the planned activities that have been completed and offered by staff that also documents the residents who have participate in the activities or do not wish to participate.

Allegation investigated: Staff did not ensure that residents were provided with activities

This is an amendment to the original report on 02/22/2024, to correct/replace pages that were created in error. At 9:30 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent visit to deliver final findings. LPA met with the House Manger, Dunhill Tolentino, and disclosed the reason for the visit. To investigate the allegation above, LPA conducted an initial complaint visit on 12/21/2023, interviews and record reviews were made. At 10:18 am, LPA requested resident, staff roster, and Administrator's certificate. At 10:30 am, LPA requested copies of pertinent information which include, but not limited to facility infection control plan, food services trainings, activities list, physician's report, appriasal needs and services plan, and etc. relevant to the investigation. At approximately 10:45 am, LPA conducted a physical plant tour with Licensee. Between 11:00am – 1:00 pm, LPA interviewed the Licensee, one (1) staff and four (4) out of five (5) residents, who were able to communicate. Continue on LIC 9099C Substantiated Staff did not ensure that residents were provided with activities It is alleged that the staff did not provide residents with activities. LPA conducted interviews with four (4) out of five (5) residents who are able to communicate, Licensee and one (1) staff member, and as well as LPA’s observation at the time of the visit to ensure activities are being held. Information from interviews revealed that since the onset of Covid-19 the facility activities routine changed. Interviews with residents did not show that the facility conducts bingo, exercise, coloring, music, etc. Interview with Licensee and staff revealed that the facility does not provide or offer that many activities since the residents do not seem interested in doing anything. During the initial visit between 9:45 AM to 3:00 PM, LPA did not observe any activities being offered to residents in care. Based on the information obtained through interviews and observation this allegation is deemed to be SUBSTANTIATED at this time. Deficiencies issued per Title 22. Exit interview conducted appeal rights explained and copy of this report signed and delivered Staff made inappropriate comments about resident while in resident’s presence To investigate this allegation, LPA conducted an interview with the Licensee and staff # 1 (S1) and was informed that the staff always takes care of all residents with dignity and respect. LPA was also informed that facility conducts monthly meetings with all staff regarding the basic services, personal rights, mandated reporter, ect. LPA conducted review of all training documents and confirmed the training is being conducted and completed. In addition, four (4) out of five (5) interviewed residents that the facility staff always treats them with respect and they do not have any concerns regarding this allegation. Based on information obtained through interviews there is not enough sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time. Staff prepared resident meals in an unsanitary manner To investigate this allegation, LPA reviewed the infection control plan and toured the facility kitchen. The kitchen was clean and sanitary. LPA conducted interviews with four (4) out of five (5) residents, one (1) staff, and the Licensee. Residents interview confirmed that the food is always clean and sanitary. They never witnessed food being prepared in unsanitary manner. Staff and Licensee interview confirmed that they always prepare food in a sanitary manner. LPA was able to observe the end of breakfast and lunch being served during the visit on 12/21/2023. LPA observed that (S1) is wearing gloves and a mask while prepare and serve food to residents. Based on information obtained through interviews there is not enough sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Feb 22, 2024 · control 31-AS-20231214102926

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a)(i) · Plan of correction due date: Mar 1, 2024

Planned activities (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation.......activities. The activities: (i) facilities shall provide sufficient equipment and supplies..... This requirement is not met as evidenced by: Based on LPAs observation and staff interview, the licensee did not comply with the section cited above by not providing or offering activities to residents in care which poses/posed a potential health, safety to persons in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Licensee shall maintain a log of all the planned activities that have been completed and offered by staff that also documents the residents who have participate in the activities or do not wish to participate.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gary Tan, met with Administrator Rose Bigornia for a One (1) Year Required visit for this facility. LPA arrived and was greeted by the administrator herself, purpose of the visit was stated. There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. A tour of the physical plant was conducted with the administrator at 12:40 PM. The facility is a single storey building with four (4) bedrooms and two (2) bathrooms currently occupying six (6) residents. One (1) additional bedroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, all of which may be bedridden. Hospice waiver for three (3) residents. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with dining The facility maintains a comfortable temperature at 76°F. The smoke detectors are hardwired and inter connected and observed to be operational. The fire extinguishers were filled and last inspected on 03/31/23.The facility is equipped with fire sprinkler system. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. The front and backyard passageways were clear of any obstruction. There is no body of water in the facility. There is no garage at the facility, only driveway at the front. Laundry area is located adjacent to the kitchen. Laundry area was observed to be locked. Laundry detergents are locked in the laundry area. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies including detergents and pesticides and other toxins are stored in a locked cabinet below the sink. Knives and sharps are observed to be kept in a locked drawer in the kitchen. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at a range of 115.2°F to 115.7°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the linen cabinet. Medications: LPA observed the medication cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. First aids kits have complete tools and supplies. Client records: Client records are reviewed and appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff record. Staff records appeared to be complete and updated. Disaster drill was last conducted on 09/05/2023. Required posting are observed to be complete and current and displayed properly at the facility. Exit interview conducted and copy of this report issued.the state’s words, verbatim · CDSS document, Oct 7, 2023