Sacramento Guest Home

Allegation investigated: ) Staff did not prevent a resident from wandering from the facility. 2) Staff did not meet the residents hygiene needs.

Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Sacramento Guest Home RCFE on 9/19/25 at 1:40pm to inform the licensee of complaint allegations mentioned above and deliver findings. LPA met with Licensee Gladys Mangabat and together discussed allegations. LPA Gould reviewed resident file and records and conducted an interview with S1 and RP. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA reviewed resident file and observed an updated physician's report that indicates R1 is able to leave the facility unassisted. LPA conducted an interview With R1's Social worker who confirmed R1 has an adequate amount of clothing and is always well groomed and clean when conducting visits with R1. Report Continued on LIC 9099-C Unsubstantiated Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of neglect/Lack of supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 19, 2025 · control 27-AS-20250917125404

Type of visit: Case Management - Deficiencies

On 9/19/25 Licensing Program Analyst (LPA) Kevin Gould conducted a Case Management Deficiencies inspection to address deficiencies observed during a complaint investigation. LPA determined that the facility is not reporting incidents as required by the department that would pose a health and safety risk to residents. LPA determined through interviews that there have been several incidents where R1 is leaving the facility without informing staff members and attempting to steal mail from neighbors, breaking into a neighbors vehicle, attempting to enter neighbors homes. The department has received no incident reports for any of the above incidents. LPA also determined an eviction notice provided to R1 did not meet department requirements and was not sent to the department within 5 days of issuance which again does not meet regulations. Additionally, upon LPA's arrival to the facility today, LPA observed the front and back doors to be open, LPA knocked and announced his presence at the facility several times. LPA encountered a resident who directed LPA to a staff bedroom where the staff member was in the bedroom with the door closed not proving supervision to residents. Per the California Code of Regulations, Title 22, the following deficiencies are cited during today's inspection. Exit interview conducted and a copy of this report and appeal rights are left at the facility.the state’s words, verbatim · CDSS document, Sep 19, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(f)87224(f) · Plan of correction due date: Sep 26, 2025

Eviction Procedures: A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met as evidenced by LPA has not received any notification of eviction for resident within 5 days of issuing the eviction to resident which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 19, 2025

Plan of correction: Licensee was issued a copy of eviction procedures. and agreed to resubmit an eviction notice that meets all requirements by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Sep 26, 2025

Reporting Requirements: Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by several incidents of resident exiting the facility and attempting to steal mail, break into cars and enter the homes of nearby neighbors which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 19, 2025

Plan of correction: Licensee has agreed to submit incident reports for all incidents identified for resident which is required to be reported to the department by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 26, 2025

Basic Services: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by upon LPA's arrival to the facility today, LPA observed the front and back doors to be open, LPA knocked and announced his presence at the facility several times. LPA encountered a resident who directed LPA to a staff bedroom where the staff member was in the bedroom with the door closed not proving supervision to residents which poses a potential health, safety and personal rights risk to residents.the state’s words, verbatim · CDSS document, Sep 19, 2025

Plan of correction: Licensee has agreed to submit a written plan of correction detailing the steps facility will take to ensure staff are always present and not in their rooms with the door closed to ensure residents received the care and supervision needed at the facility.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Gould conducted unannounced required 1 year annual inspection visit. LPA met with administrator and stated the purpose of today’s visit. LPA and administrator toured the physical plant including resident bedrooms, resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 114 degrees Fahrenheit in resident bathroom sink which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. LPA checked medication storage and found medication to be locked away and inaccessible to residents. First aid kit was checked and is complete. LPA reviewed five resident files and four staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview held with administrator. A copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Aug 28, 2025

Allegation investigated: Facility staff are not taking sufficient measures to address bed bug infestation

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to open this complaint investigation. LPAs Moleski and Williams met with licensee Gladys Mangabat and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. LPAs Moleski and Williams interviewed Mangabat, a resident (R1), a resident's responsible party (R1's RP), and a pest control contractor. Mangabat had been aware of a bed bug infestation since around mid-June. Mangabat said she had contracted with a pest control company to have monthly chemical sprayings done. Mangabat also said she had implemented several additional pest control measures, including encasing residents' mattresses, performing hot-water laundry services, localized heat treatments with a heat gun, and enhanced environmental cleaning with alcohol-based solution. [continued on 9099-C] Unsubstantiated LPAs Moleski and Williams toured the facility and observed mattresses which had been encased. In an interview, a pest control contractor confirmed having performed chemical treatments on or around June 26, 2024 and confirmed that a representative will be returning to this facility on or around July 28, 2024. In an interview, R1 said that after they had mentioned the infestation to Mangabat, that Mangabat quickly took measures to mitigate the situation. R1 said that Mangabat helped to clean R1's room, and encased R1's mattress, and performed heat treatments in R1's room. R1 said that they are not being bitten any more after the pest control company visited. LPA Moleski reviewed a contract between Mangabat and the pest control company dated June 11, 2024. The contract did not include a termination date. Mangabat said she would be retaining these services monthly on an ongoing basis. The department has determined the following as it relates to the allegation that facility staff are not taking sufficient measures to address bed bug infestation: Based on interviews, observation, and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Mangabat.the state’s words, verbatim · CDSS document, Jul 15, 2024 · control 27-AS-20240709164336

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to open a complaint investigation. LPAs Moleski and Williams met with licensee Gladys Mangabat and explained the purpose of the visit. LPAs Moleski and Williams investigated a complaint regarding measures taken to address a bed bug infestation. Mangabat had been aware of the infestation since at least June 11, 2024, based on a contract signed by her and a representative of a pest control company. Mangabat verbally acknowledged the infestation and said she had not sent in an incident report to the Community Care Licensing Division. LPAs Moleski and Williams received no incident reports regarding this infestation. This facility is hereby cited per 22 CCR Section 87211(a)(1)(D). An exit interview was held with Mangabat. Appeal rights and a copy of this report were left with Mangabat.the state’s words, verbatim · CDSS document, Jul 15, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jul 29, 2024

"(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:.. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident." This requirement was not met as evidenced by: Based on interviews, observation, and record review, an incident report was not sent in after an outbreak of bed bugs at this facility, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Jul 15, 2024

Plan of correction: Licensee agrees to send LPA Moleski an incident report, and to review the applicable 22 CCR sections regarding reporting requirements, and to send LPA Moleski a signed statement acknowledging these requirements by POC due date. vincent.moleski@dss.ca.gov

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required 1 year annual inspection visit. LPA met with administrator and stated the purpose of today’s visit. LPA and administrator toured the physical plant including resident bedrooms, resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 108.8 degrees Fahrenheit in resident bathroom sink which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguishers last serviced 8/3/2023. LPA checked medication storage and found medication to be locked away and inaccessible to residents. First aid kit was checked and is complete. Fire/Emergency Disaster Drill last conducted 5/23/2024. LPA reviewed six resident files and four staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview held with administrator. A copy of report and LIC 811 (Confidential Names) given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Jun 16, 2024

Allegation investigated: Resident was served unlawful eviction notice Facility is in disrepair Facility is unclean Waste was stored in an unsafe manner

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to open this complaint investigation. LPA Moleski met with facility administrator Gladys Mangabat and explained the purpose of the visit. LPA Moleski reviewed this facility's house rules and an eviction notice for R1. The eviction notice stated that R1 was being evicted effective as of 4/4/24 due to marijuana use and inappropriate behaviors, including arguing with roommates. The notice did not contain a sufficient amount of detail, such as time and dates, nor did it contain the required information about unlawful detainers, nor did it contain information about residents' rights to file a complaint, nor did it contain contact information for CCLD, and therefore was not lawful. LPA Moleski toured this facility. LPA Moleski and Mangabat observed in the ktichen a dish on the floor containing chicken scraps. Mangabat said it was for her dog. LPA Moleski and Mangabat observed an uncovered container on the counter containing waste. Mangabat said it was compost, and covered the container. [continued on 9099-C] Substantiated LPA Moleski and Mangabat observed rodent droppings on the carpet in a resident's room. LPA Moleski and Mangabat observed in this same resident bedroom a mattress with what appeared to be feces stains on it. LPA Moleski and Mangabat observed in all resident bathrooms uncovered waste bins containing toilet paper soiled by what appeared to be feces. LPA Moleski and Mangabat observed damage to moulding in one of these bathrooms that was broken. Pieces of the moulding were observed broken and lying on the floor. The bathroom floor near the broken moulding was covered in a brownish colored, moist substance. Mangabat said there may be a soap leak. LPA Moleski observed the back patio to be in reasonably good condition and did not appear to be in disrepair. The department has determined the following as it relates to the allegations that a resident was served an unlawful eviction notice, that the facility is in disrepair, that the facility is unclean, and that waste was stored in an unsafe manner: Based on observation and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met. This facility is being cited per 22 CCR Sections 87224(d)(1)(B-D), 87470(a)(2)(D), and 87303(a). An exit interview was held with Mangabat. Appeal rights and a copy of this report were left with Mangabat.the state’s words, verbatim · CDSS document, Apr 8, 2024 · control 27-AS-20240405101732

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d)(1)(B-D) · Plan of correction due date: Apr 15, 2024

"(1) The notice to quit shall include the following information: ... (B) Resources available to assist in identifying alternative housing and care options which include, but are not limited to, the following: 1. Referral services that will aid in finding alternative housing. 2. Case management organizations which help manage individual care and service needs. (C) A statement informing residents of their right to file a complaint with the licensing agency, as specified in Section 87468, subsection (a)(4), including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office. (D) The following exact statement as specified in Health and Safety Code Section 1569.683(a)(4): "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing." This requirement was not met as evidenced by: Based on record review, licensee served an unlawful eviction notice, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Apr 8, 2024

Plan of correction: Licensee agrees to write a letter to R1 and R1's responsible party notifying them that this eviction notice is no longer in effect. Licensee shall send LPA Moleski a copy of the letter. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Apr 9, 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." This requirement was not met as evidenced by: Based on observation, the facility was not clean in a resident's room and in the kitchen, and, in addition, one facility bathroom was in disrepair, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Apr 8, 2024

Plan of correction: Licensee agrees to clean the facility and obtain repair services by the POC due date. Licensee shall provide photos to LPA Moleski afterward. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(a)(2)(D) · Plan of correction due date: Apr 9, 2024

"(D) Facility items that cannot be disinfected shall be discarded immediately in an appropriate waste receptacle with a tight-fitting cover or otherwise made inaccessible to human contact or transmission." This requirement was not met as evidenced by: Based on observation, hazardous waste capable of spreading disease, i.e. feces, was kept in an uncovered container in facility bathrooms, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Apr 8, 2024

Plan of correction: Licensee agrees to remove the bins and instruct residents to flush soiled toilet paper down the toilet by POC due date. Licensee agrees to put up signs in bathrooms to this effect. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to open a complaint investigation. During the course of this investigation, LPA Moleski observed unrelated deficiencies. LPA Moleski met with facility administrator Gladys Mangabat and explained the purpose of the visit. While touring this facility, LPA Moleski and Mangabat observed Tylenol unsecured in a resident's room. LPA Moleski and Mangabat observed a cleaning product containing bleach left unsecured in a cabinet in a resident bathroom. This facility is being cited per 22 CCR Sections 87309(a) and 87465(h)(2). An exit interview was held with Mangabat. Appeal rights and a copy of this report were left with Mangabat.the state’s words, verbatim · CDSS document, Apr 8, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Apr 9, 2024

"(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients." This requirement was not met as evidenced by: Based on observation, a cleaning solution was accessible to residents, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Apr 8, 2024

Plan of correction: Licensee removed the cleaner during this visit. LPA Moleski shall return to reassess compliance.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Apr 9, 2024

"(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." This requirement was not met as evidenced by: Based on observation, medication was accessible to a resident, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Apr 8, 2024

Plan of correction: Licensee removed the medication during this visit. LPA Moleski shall return to reassess compliance.