Rancho Santa Fe Villa

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit regarding a deficiency cited on 4/27/26 as well as a Plan of Correction (POC) visit to follow-up on two (2) deficiencies cited 5/13/26. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Licensee/Administrator Ray Baha. On 4/27/26 during the facility's required annual inspection, LPA cited a deficiency for the facility locking exterior doors without having the fire clearance to do so. POC has since been met and the deficiency cleared (as of 5/22/26). However, as the violation was a Zero Tolerance Violation (ZTV), an immediate Civil Penalty of $500.00 has been assessed today as it was not assessed on the day of the deficiency on 4/27/26. Details are included on the attached LIC 421IM. On 5/13/26 LPA cited a deficiency for the facility having not met reporting requirements. POC due date was set for 5/22/26 and was: "Licensee will submit an incident report of the event to Community Care Licensing by POC due date. Licensee will review 87211 and submit to LPA by the POC due date the facility's plan to ensure ongoing compliance with reporting timelines moving forward." While the Department received an incident report on 5/15/26 for the incident that took place 4/24/26, LPA had not received the secondary POC item by the due date, nor communication from the Licensee requesting for an extension. As the Licensee failed to correct the deficiency and notify LPA by the due date, LPA conducted a POC visit to verify correction and to assess a Civil Penalty Violation for Failure to Correct. A Civil Penalty of $100.00 a day has been assessed from 5/23/26 through today's date 6/2/26 for a total of $1,100.00. Details are included on the attached LIC 421FC. Licensee was able to provide LPA POC items during the visit and LPA cleared the deficiency. POC clearance letter was provided to Licensee Baha. [Continued on LIC 809-C] [Continued from LIC 809] Additionally on 5/13/26 LPA cited a deficiency for the facility violating the right for residents to receive unopened correspondences. Please see complaint 08-AS-20260512093839 for additional information. POC due date was set for 5/15/26 and was: "Licensee will promptly provide any mail/correspondences for R1. Licensee will submit a written statement to LPA that they have provided R1 their packages and will continue to do so promptly for future packages. Licensee will submit proof to LPA by POC due date." LPA had not received POC items by the due date, nor communication from the Licensee requesting for an extension. As ten (10) working days have passed since the POC due date, LPA cannot issue a Civil Penalty for Failure to Correct. The deficiency is being re-cited today and details are included on the attached LIC 809-D page. Licensee was able to provide POC items during today's visit and LPA cleared the deficiency. LPA provided the POC clearance to Licensee/Administrator Baha. One deficiency was cited during today's visit along with two (2) Civil Penalty assessments. An exit interview was conducted with Licensee/Administrator Baha to whom a copy of this report, the two (2) POC clearance letters, the LIC 421IM, LIC 421FC, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jun 2, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(15) · Plan of correction due date: Jun 3, 2026

87468.1(a): "Residents in all residential care facilities for the elderly shall have all of the following personal rights: (15) To send and receive unopened correspondence in a prompt manner." This requirement is not met as evidenced by: Based on LPA file review and interview, the licensee did not comply with the section cited above in ensuring a resident's right to receive unopened correspondences in a prompt manner was upheld, which poses a potential personal rights risk to 1 out of 4 persons in care.the state’s words, verbatim · CDSS document, Jun 2, 2026

Plan of correction: Licensee will promptly provide any mail/correspondences for R1. Licensee will submit a written statement to LPA that they have provided R1 their packages and will continue to do so promptly for furture packages. Licensee will submit proof to LPA by POC due date.

Type of visit: Office

On May 20th, 2026, an informal meeting was held at the San Diego Regional Office. In attendance were Licensee/Administrator Ray Baha, Licensing Program Analyst (LPA) Arian Golbakhsh, and Licensing Program Manager (LPM) Sabel Martinez. During the meeting, the department addressed the licensees’ questions, provided consultation on the Health & Safety Code and the California Code of Regulations, Title 22, and discussed ongoing collaboration with the department. Specific regulation topics discussed included resident personal rights, care for persons with Dementia, and reporting requirements. Copies of applicable regulations were provided to Licensee/Administrator Baha. In addition, LPM Martinez explained Licensee rights, including the right to appeal, the right to jointly develop plans of correction, and, the availability of waivers where applicable. LPM introduced the department’s optional Technical Support Program and distributed related materials. A copy of this report, laws and regulations discussed, and licensee appeal rights were provided to License/Administrator Baha, whose signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 20, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to the facility. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Licensee/Administrator Ray Baha. While conducting interviews and file review, LPA was informed by staff of an incident regarding a resident "a few Friday's ago," in which the resident (identified as R1) had obtained alcohol via physical mail and consumed it. Per file review and staff interviews, R1 has a documented history of alcohol and substance abuse. LPA had additionally conducted an interview with an outside source responsible for R1's care and it was revealed that the incident occurred prior to May 6th, 2026 though no specific date of the incident had been given. Community Care Licensing (CCL) had not received any notification from the facility of any such incident within the required seven (7) days. A Type B deficiency for not meeting reporting requirements was issued, and details are included on the attached LIC 809-D page. LPA offered consultation for possible next steps regarding concerns that R1 may no longer be safely able to manage their mail. Licensee/Administrator Baha stated they do not believe the incident fell under the criteria of an incident requiring notification to CCL and requested this to be included in today's report. One Deficiency was cited during the visit. An exit interview was conducted with Licensee/Administrator Baha to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 22, 2026

87211(a):Each licensee shall furnish to the licensing agency [...] (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 requirement is not met as evidenced by: Based on LPA file review and interview, the licensee did not comply with the section cited above in meeting timelines for reporting requirements, which poses a potential health, safety, and personal rights risk to all persons in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: Licensee will submit an incident report of the event to Community Care Licensing by POC due date. Licensee will review 87211 and submit to LPA by the POC due date the facility's plan to ensure ongoing compliance with reporting timelines moving forward

Type of visit: POC

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Plan of Correction (POC) visit regarding a deficiency that was cited on April 27, 2026. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Licensee/Administrator Ray Baha. On 4/27/26 LPA cited a deficiency for the facility locking all exterior doors without having the fire clearance to do so. The POC due date was set for May 25th, 2026. During an unrelated visit to the facility today, Licensee/Administrator Baha requested LPA consultation on the POC. Per Licensee Baha, they plan to continue following the POC plan by reaching out to their local fire department/fire marshal to inquire on consultation for the facility on having locked exterior doors, but that they believe the process may take more time than planned. Licensee Baha asked if LPA could extend the POC due date by an additional week and LPA agreed. The new due date for POC will be Monday, June 1st 2026. LPA examined exterior door noted and noted them to be unlocked. An exit interview was conducted with Licensee/Administrator Baha to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 12, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Caregivers Weny Labuguin and Angelita Hernandez. Administrator Ray Baha arrived shortly after LPA. The facility's license shows a maximum capacity of six (6) non-ambulatory residents. Bedrooms #1, #4, #5, and #6 are approved for bedridden. Additionally, the facility is approved for a hospice waiver for six (6). During today’s inspection there were four (4) residents in care, with none currently on hospice. Note, LPA did step out from 12:50-1:50 for lunch. LPA and Administrator Baha toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: common bathroom sink adjacent to bedroom #7 was 107.2F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were locked and inaccessible to residents. While looking at the unlocked cabinet under the sink, LPA observed a number of cleaning chemicals. One type A deficiency was issued for the accessible chemicals to residents. Staff immediately moved the items to a locked storage room. [Continued on LIC 809-C] [Continued from LIC 809] Additionally, while touring the enclosed courtyard at the center of the home, LPA was shown the doorway to the garage area. LPA observed that the door was only lockable from the inside and was currently unlocked. Inside the garage were a number of chemicals, in addition to an accessible door into the medication/chemicals storage room. Per Administrator Baha, the facility was in the process of changing several locks (garage door included) in the home so that they are all accessible by the same key for efficiency. Administrator Baha locked the doorway from the inside and exited through the lifting garage door so that the garage was no longer accessible to residents. LPA observed that the doors to the enclosed courtyard space were unlocked, allowing for resident access. However, the exterior doors of the home leading outside were all locked aside from the front door and required a key to open. The facility does not have approval for locked exterior doors and/or a locked perimeter. Administrator Baha explained that the exterior yard is not safe for resident use and the enclosed courtyard is the designated outdoor space for resident use. One type A deficiency was cited for the unapproved locked exterior doors. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Administrator Baha, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months, dated for February 2026. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA observed a private care aid (identified as S1) who was present at the facility for their assigned resident (identified as R1). LPA requested S1's background clearance from the facility for review and was informed that they did not have it on file. Per interview with S1, it was revealed S1 was not employed by a private care agency. Upon review of the Guardian background check database, it was revealed that S1 had not undergone the LiveScan process (fingerprint submittal and background check). One Type A deficiency was issued for S1 providing care and supervision services on the premises without a required background check. LPA ensured S1 was escorted off the premises. [Continued on LIC 809-C] [Continued from LIC 809-C] While at the facility, LPA observed five (5) camera monitor systems displaying common facility areas and the inside of four (4) resident rooms, along with audio from each space. Per Administrator Baha, the responsible parties of the residents were aware of the use of cameras in private spaces and gave permission. While the use of surveillance cameras are not expressly prohibited in Title 22 regulations, efforts to protect resident privacy must be maintained by the facility and a waiver request must be submitted to the Department for camera use in private resident rooms. An audio component for video surveillance in facilities is strictly prohibited. One Type B citation was issued for the use of video and audio surveillance in private areas of the facility without Department approval. Administrator Baha turned off all five monitors. LPA interviewed two (2) staff and one (1) clients, and interviews did not reveal any additional licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. LPA noted consent forms signed by resident responsible parties included in the files of only three (3) of the four (4) resident rooms that contained cameras. Four (4) deficiencies were cited during the inspection. An exit interview was conducted with Administrator Baha to whom a copy of this report, the LIC 421BG form, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Apr 27, 2026

Allegation investigated: Staff were unqualified. Facility did not have an auditory device at exit doors Facility did not have sufficient staff to meet a resident’s needs Staff did not follow admission agreement

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced follow up complaint investigation visit and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Administrator Ray Baha. Throughout the investigation, the Department secured records and conducted interviews with external and internal sources, including staff and residents. It was alleged staff were unqualified. On August 26th, 2024, it was reported to the Department that staff were not able to communicate with residents. Interviews with internal and external sources did not reveal any concerns with staff not understanding residents or not being able to communicate. (See LIC 9099-C for continuation of report.) Unsubstantiated One source reported it could be frustrating to communicate with one of the staff members, but this source also disclosed there were multiple staff present to address any misunderstanding. Additionally, the LPA conducted interviews with facility staff and was able to hold conversations.The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. It was alleged the facility did not have auditory devices at exit doors. On August 26th, 2024, it was reported to the Department several exit doors at the facility did not have auditory devices. During an unannounced visit, the LPA witnessed several exit doors did not have auditory devices. The LPA also witnessed several of the exit doors were covered with plastic coverings. An interview with the administrator revealed the facility was in the process of painting a portion of the facility and some of the auditory devices were removed to avoid any damage to the devices. Records reviewed for the four residents in care revealed one resident was diagnosed with Mild Cognitive Impairment (MCI), but did not require assistance with activities of daily living and could leave the facility unassisted. One resident was diagnosed with dementia but required assistance transferring out of bed. Two residents were diagnosed with MCI and one required assistance with transferring out of bed. The second resident with MCI was ambulatory and could be confused at times. Per Dementia Care regulations, the facility must have auditory devices, or alert features to monitor exit doors when residents are at risk of elopement. There were no noted behaviors of wondering, or elopement from any of the residents, and the resident diagnosed with dementia required assistance with transferring out of bed. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. It was alleged the facility did not have sufficient staff to meet a resident’s needs. On August 26th, 2024, it was reported staff did not respond to assist a resident, because there was insufficient staffing. Interviews with internal and external sources did not have any concerns with staff not having sufficient staff. Interviews with the administrator and staff revealed the facility did not maintain hard copies of schedules, but there were two to three staff working the first shift from 7 AM to 7PM. There were at least two staff at the facility during the second shift from 7 PM to 7AM. (See additional LIC 9099-C for continuation of report.) The administrator resided at the facility and would assist when needed. Review of resident records revealed there were four residents residing at the facility. One resident did not require assistance with activities of daily living and was independent. The remaining three residents required assistance with transferring, dressing, bathing, and toileting. One of these residents employed a private caregiver Monday through Friday from approximately 9 AM to 5pm. Based on the evidence obtained the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. It was alleged staff did not follow an admission agreement. On August 26th, 2024, it was reported to the Department that the facility did not assist Resident # 1 (R1) with daily exercises, nor room cleaning as indicated in the admission agreement. Staff reported staff would attempt to clean R1’s bedroom on a weekly basis, but R1’s spouse, who also resided at the facility, would decline and discourage staff from assisting R1. Staff would assist R1 with exercises, but R1’s health had declined and R1 spent more time sleeping or sitting on R1’s chair. Interviews with additional internal and external sources did not have any concerns with lack of bedroom cleaning, nor with the admission agreement not being followed. Based on the evidence obtained, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator Ray Baha, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058),were provided.the state’s words, verbatim · CDSS document, May 20, 2025 · control 08-AS-20240826160702

Allegation investigated: Staff did not meet resident's needs

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Administrator Ray Baha. Throughout the investigation, the Department secured pertinent records and conducted interviews with external and internal sources, including staff and residents. It was alleged staff did not meet a resident's needs. On September 5th, 2024, it was reported staff were not meeting Resident # 1’s (R1) needs. The reporting party reported the facility administrator mentioned R1’s spouse, Resident # 2 (R2), had declined a hospital bed for R1, as ordered by home health. This allegedly hindered the facility’s ability to meet R1’s needs. (See LIC 9099-C for continuation of report.) Unsubstantiated An interview with the administrator revealed there was no order from R1’s home health agency, but instead the administrator had suggested a hospital bed for R1. R2 declined the hospital bed but agreed to allow the administrator to reduce the height of R1’s bed frame. Although R2 would decline suggestions from the administrator, staff were still able to meet R1’s needs. An interview with the home health agency that provided services to R1 revealed there was no order, nor suggestion for a hospital bed. The agency disclosed R2 was very involved in R1’s care and preferred a homeopathic approach to R1’s care. Per home health, there was no indication that R1’s needs were not being met at the facility. Interviews internal and external sources did not reveal any concerns with staff not meeting the residents’ needs. The Department attempted to interview R1 on multiple occasions, but these attempts were not successful. Based on the evidence obtained, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator Ray Baha, to whom a copy of this report, and Licensee Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, May 20, 2025 · control 08-AS-20240905151848

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced case management visit to address a deficiency discovered during a complaint investigation. The LPA identified himself and disclosed the purpose of the visit to Administrator Ray Baha. During a complaint investigation, it was revealed staff had not assisted residents with incontinence care. Review of records revealed several residents in care required assistance with toileting and incontinence care. The administrator confirmed several residents required assistance with toileting/ incontinence care and that staff assisted these residents with this care. Although staff reported providing care during the night shift, conducted random checks, and residents could call for assistance; Interviews with internal and external sources corroborated staff did not ensure incontinence residents were kept clean and dry. One source reported witnessing Resident # 1 (R1) with soiled incontinence briefs. An interview with an additional source revealed staff would only check on R1 once per night, and this had resulted in R1 sitting in soiled incontinence briefs. An additional source reported staff did not respond to assist Resident # 2 (R2) with briefs changes resulting in R2 wearing soiled briefs. This deficiency was cited in accordance with California Code of Regulations, Title 22, and cited in an LIC 9099-D form. A plan of correction was jointly formulated with the administrator. An exit interview was conducted with Ray Baha, to whom a copy of this report, and Licensee/Appeal Rights (LIC9058), were provided.the state’s words, verbatim · CDSS document, May 20, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87626(b)(3) · Plan of correction due date: May 20, 2025

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry... This requirement was not met as evidenced by: Based on interviews and review of records, the licensee did not ensure R1 and R2 were kept clean and dry, which posed an potential health, safety, and personal rights risk to two residents in care.the state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: Administrator agreed to provide incontinence care training to all staff by 6/20/25. Administrator will submit proof of training to the LPA by 6/20/25.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Caregiver Weny Labuguin. Administrator Ray Baha arrived later during the visit. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, four (4) of which may be bedridden. Bedridden residents may reside in rooms 1, 4, 5, and 6. The facility also has a hospice waiver for six (6). During today’s inspection there were two (2) residents in care. LPA and Administrator Baha toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Bathroom sink in client room 1 was 108F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. [Continued on LIC 809-C] [Continued from LIC 809] No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Administrator Baha, no firearms or ammunition are kept at the facility. Carbon monoxide detectors and emergency lighting were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete aside from missing a first aid manual, and a Technical Violation (TV) was issued. Required licensing postings were observed in visible areas of the facility. The last fire drill completed was conducted on 3/25/25. LPA interviewed two (2) staff and two (2) clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Administrator Baha to whom a copy of this report and TV form were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Apr 17, 2025

Allegation investigated: Facility had uncleared staff. Required postings were not visible. Facility did not conduct emergency drills

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced complaint investigation visit and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Weny Labuguin. Administrator Ray Baha arrived during the visit and assisted the LPA. Throughout the investigation, the Department secured pertinent records and conducted interviews with external and internal sources, including staff and residents. It was alleged the facility had uncleared staff. On August 26th, 2024, it was reported to the Department the facility had hired Staff # 1 (S1), but S1 was not background cleared to work at the facility. Interviews with internal and external sources revealed S1 was a private caregiver providing services to a resident at the facility. (See LIC 9099-C for continuation of report.) Substantiated These interviews, including the administrator and S1, corroborated S1 was asked to work for the facility for two days, while regular care staff were off. Review of the Department’s background clearance database revealed S1 was not associated to the facility and did not have a background clearance. Based on the evidence obtained, the deficiency was cited in an LIC 9099-D form. An immediate two hundred dollar ($200) civil penalty was assessed in an LIC 421BG form. It was alleged required postings were not visible. It was reported to the Department the required postings, including the Department’s “If you see something, Say something” poster, were posted in a section of the facility the residents did not use. Interviews with staff, including the administrator, confirmed the section of the facility where the postings were was not regularly used by residents. The area was used for meetings. The LPA observed some of the postings were not visible. The deficiency was cited in an LIC 9099-D form. It was alleged the facility did not conduct emergency drills. It was reported to the Department residents had not participated in emergency drills. Interviews with several staff revealed the facility conducted drills every three months. The type of drills varied between fire, and earthquake emergencies. Review of records revealed the facility documented the date of the drill, and staff who participated, but not the time. An interview with the administrator revealed the facility did not conduct drills on every scheduled shift. Per regulations, the residents are not required to participate in emergency drills, but the facility must conduct drills at least quarterly for each shift. This deficiency was cited in an LIC 9099-D form. Plans of Corrections (POCs) were jointly formulated with Administrator Baha. An exit interview was conducted with Baha, to whom a copy of this report, LIC 9099D forms, LIC 421BG, LIC 811, and Licensee/Appeals Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Apr 11, 2025 · control 08-AS-20240826160702

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Apr 11, 2025

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department... This requirement was not met as evidenced by: Based on interviews, and review of records, the Licensee did not ensure S1 had a criminal records clearance, which posed an immediate health, safety, and personal rights risk to 4 residents in care.the state’s words, verbatim · CDSS document, Apr 11, 2025

Plan of correction: Administrator agreed to obtain criminal records clearances for all new staff. Administrator stated S1 no longer worked at the facility. The LPA did not observe S1 at the facility, therefore, the POC was cleared on today's date. S1 was background cleared and associated after, 9/4/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(10) · Plan of correction due date: Apr 11, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(10)...regarding grievances in regard to the licensee. The licensee shall post the telephone numbers and addresses for the local offices of the State Department of Social Services and ombudsman program, according to Section 9718 of the Welfare and Institutions Code, conspicuously in the facility foyer, lobby, residents’ activity room, or other location easily accessible to residents and their representatives. This requirement was not met as evidenced by: Based on interviews and observations, the Licenssee did not ensure these postings were conspicuously posted where residents could see them, which posed a potential health, safety and personal rights risk to 4 residents in care.the state’s words, verbatim · CDSS document, Apr 11, 2025

Plan of correction: Administrator agreed to post required postings in a hallway where they are visible to all residents, by 5/2/25.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(c) · Plan of correction due date: Apr 11, 2025

§1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is notrequired during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement was not met as evidenced by: Based on review of records and interviews, the Licensee did not ensure emergency drills were conducted for each shift, which posed a potential health, safety, and personal rights risk to 4 residents in care.the state’s words, verbatim · CDSS document, Apr 11, 2025

Plan of correction: Administrator agreed to conduct an emergency drill during each shift and submit proof to the LPA by 5/2/25.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA identified himself to and disclosed the purpose of the visit to Caregiver Weny Labuguin. The facility was licensed for a capacity of six (6), of which four (4) could be bedridden in rooms 1,4,5, and 6. At the time of the visit, the census was two (2). The LPA, accompanied by caregiver, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, and stored in locked areas. No pools, or bodies of water were observed on the premises. Per staff, no firearms or ammunition were kept at the facility. A carbon monoxide detector, facility telephone, and fire extinguisher were present. Required licensing postings were observed in a visible area of the facility. The LPA interviewed staff and reviewed multiple staff and resident records/files. The files which LPA reviewed contained required documents. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Caregiver Labuguin, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058), were provided.the state’s words, verbatim · CDSS document, Apr 30, 2024